Therapy Request Form - Ellie Mental Health, Palatine

Therapy Request Form - Ellie Mental Health, Palatine

By completing this form, you consent to have our team leave a generic voicemail and email offering more information. No specific information regarding your request will be included within the voicemail or email.
To request an appointment, please complete the following form. A member of the Ellie Client Access team will be in touch within 2 business days.
Name

First NameLast Name
Is the person seeking services a minor?

YesNo
Pronouns
Sex
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Are you following a provider that is moving to Ellie?
Please provide a brief summary describing your goals in therapy or the type of support or services you are seeking:*
What is your insurance carrier?
Please verify that you are human*
How did you hear about us?*

Internet Search (Google)Friend or Family MemberAnother Provider (ie. Doctor, case manager)An online advertisement (Facebook/YouTube)Other Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)Other
Should be Empty: