Contact Form
Our team will contact you within 24-48 hours upon completion of this form. You can also reach us at 630-635-0577 Ext 0 with any questions
Legal Name
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do we have your permission to contact you via text message or SMS strictly for scheduling purposes? Messaging frequency may vary. Message and data rates may apply.You can opt out any time by texting STOP. For assistance, text HELP or visit our website at www.bluekitewellness.com. Visit https://bluekitewellness.com/privacy-policy for privacy policy & SMS Terms of Service.
*
Yes
No
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance:
*
Please Select
Aetna Better Health
Aetna PPO
Blue Cross Community Health
Blue Cross Blue Shield PPO
Cigna
County Care
IL Medicaid
Medicare
Meridian
Molina
Tricare
United Health
UMR
Youthcare
Other/Don't Know
Services Requested:
*
Counseling/Therapy (In Person)
Counseling/Therapy (Telehealth)
Medication Management / Psych Evaluation (Not accepting new clients)
How did you hear about Blue Kite?
*
Please Select
Google
Psychology Today
Primary Care Physician
Friend
Instagram/Facebook
LinkedIn
Other
Please tell us where:
Please describe your main concerns & goals we can help with:
If able please upload - Front & Back Of your Insurance Card & Photo Id. This helps us expedite your request and set up your appointment.
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