PHP & IOP Inquiry Form

PHP & IOP Inquiry Form

Complete the details below and a member of our team will get back to you.
Full Name*

First NameLast Name
I'm interested in learning more about your PHP/IOP treatment options for...*

MyselfA loved oneA client
This is for a:*

Child/Adolescent (ages 13-17)Adult (ages 18+)
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Feel free to tell us what is happening...
When is the best time for us to contact you?*
Please provide days and times.
I am interested in learning more about PHP/IOP at the following location:*
The PHP/IOP program at the location you have selected will be opening soon. Complete and submit this form to be notified of when this location will begin screening for program intake.

Looking for immediate PHP/IOP program availability? Try our in-person PHP/IOP programs at our Chicago Loop location or our Virtual IOP program.
My preferred time of day to attend a PHP/IOP Program is:*

8:30am - 11:30am4:30pm - 7:30pm12:00pm - 4:00pmNo preference

Schedule a PHP/IOP Consultation

If you are a referring client, please fill out the below fields with your patient's information.
Insurance Provider
Date of birth

MonthDayYear
Date
Please enter your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Optional: Check Your Insurance Coverage

If you would like us to check your insurance benefits, please provide the following information. If you do not wish to provide your insurance information at this time, please submit your form as is.
Insurance Provider Phone Number
Member ID Number
Upload a photo/scan of the front AND back of your insurance card

This will help speed up the process to check your insurance benefits
Cancelof
Subscriber's Last Name
Subscriber's First Name
Insurance Address as Listed on Your Insurance Card

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber's Relationship to Client

SelfSpouseParent/GuardianOther
Should be Empty:

Schedule a PHP/IOP Consultation