Let's Get You Started!

Let's Get You Started!
Hello! Thank you for selecting Milestones Counseling Center PLLC for your mental health services. Before we collect more detailed information, we’ll start by asking you to select your insurance company and plan. This quick step helps us make sure you’re starting on the right path, so you don’t spend time filling out intake paperwork only to find out we aren’t in-network. Once you select your plan, we’ll guide you through the rest of the process.
Your Name*

First NameLast Name
Client's Name (if you are completing this form for someone else)

First NameLast Name
Your Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Would You Like To Receive Our Agency Updates?
Our agency updates contain information on MCC events, clinician interviews, mental health tips, therapy openings, emergency/weather office closures, etc. Would you like to be added?*

YesNo
How did you hear about us?*

InsuranceEAPFacebookGooglePrevious/Current ClientZocdocPsychology TodayCommunity Event (Parade, Trick or Treat Trail, Country Christmas)Mental Health FairSaw the Sign in Front of the OfficeOther
We Currently Accept the Following Insurance Plans:

Private Insurance
- Aetna PPO
- Blue Cross Blue Shield PPO
- Cigna
- United Healthcare/ Optum
Medicaid
- Traditional Medicaid (No additional MCO)
- Blue Cross Community
Do you have one of the insurance plans listed above?

YesNoI'm not sureI would like to pay out of pocket for services.
Let’s Take a Closer Look at Your Insurance

Before completing any paperwork, please take a moment to call our office at 708-880-7747 to confirm whether we accept your insurance. Some insurance plans have multiple names or companies associated with them. This quick call can save you time and ensure you're on the right path from the start. We’re happy to help!
We accept your plan! Please select the most appropriate statement.

I am ready to start services and would like to schedule an intake appointment.I would like to schedule a free 15-minute phone consultation. (Please note that our scheduling system requires a credit card to be on file in order to schedule. You will NOT be charged anything for this consultation. If you prefer not to put a card on file, you can call our office and schedule your consultation.)I'd like someone to call me to discuss my options. We aim to return all call requests within 2 business days. Feel free to call our office at 708-880-7747.
What is your relationship to the client?

SelfSpouse/PartnerParentLegal GuardianOther
Client's Age
Client's Phone Number (Guardian for a Minor)
Before you Schedule an Appointment, Let's Fill Out Your Intake Paperwork

Once you submit this form you will be taken to the appropriate intake forms. Once those are submitted you'll be directed to Simple Practice to schedule an appointment.
Just a Few More Steps to Schedule a Free 15-Minute Consultation

Once you submit this form you will be taken to Simple Practice to schedule a Free 15 Phone Minute Consultation.
In order to direct you to the correct intake paperwork, please select the statement below that best describes your relationship to the client.

I am 18 and older and I am seeking services for myself.I am 12-17 years old and I am seeking services for myself.I am the parent/guardian of a youth aged 6-11 who is in need of services.I am the parent/guardian of a youth aged 12-17 who is in need of services.If the above statements do not apply, please contact our office at 708-880-7747 for more information.
For Youth Ages 12 & Up

Important Note About Intake Paperwork- Due to privacy and consent laws, both the youth and their parent or guardian are required to complete separate sets of intake paperwork. This ensures we have the proper permissions to provide care and that the youth’s voice is included in the process. Thank you for your cooperation!
Click Submit Below and You Will Be Taken to the Next Step.
Click Submit Below and our Client Care Coordinator Will Reach Out to You.
Should be Empty:

Let's Get You Started!

Would You Like To Receive Our Agency Updates?

Let’s Take a Closer Look at Your Insurance

Before you Schedule an Appointment, Let's Fill Out Your Intake Paperwork

Just a Few More Steps to Schedule a Free 15-Minute Consultation

For Youth Ages 12 & Up

Click Submit Below and You Will Be Taken to the Next Step.

Click Submit Below and our Client Care Coordinator Will Reach Out to You.