Appointment Request

APPOINTMENT REQUEST

Samaritan Counseling Center of the Northwest Suburbs
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County
Email
example@example.com
Phone Number
Please enter a valid phone number.
Client's Name (if different from above)

First Name Last Name
Birth Date

Month Day Year
Insurance
Member ID
Group #
Insurance Phone #
Please enter a valid phone number.
Name of Insurance Policy Holder

First Name Last Name
Date of Birth for Insurance Policy Holder

Month Day Year
If EAP, Name of EAP
EAP Phone #
Please enter a valid phone number.
Employer
Employer Phone #
Please enter a valid phone number.
EAP Authorization Code
Reason For Counseling (e.g., anxiety, depression, stress, etc.)
Availability
Should be Empty: