Appointment Request Form
Please complete the form below so we can provide the best match to an available clinician.
Contact E-mail
*
Contact Full Name
*
First Name
Last Name
Contact Phone Number
*
-
Area Code
Phone Number
Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would you like to conduct sessions?
In person at the Arlington Heights Office
In person at the Crystal Lake Office
Telehealth (online)
The sessions will be for:
Myself
A child or family member
A couple
Other
Patient Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Patient's Primary Care Physician (PCP):
For Couples Therapy or Family Therapy please list the names and ages of all participant's:
Please select clinical service(s) or treatment(s) you're requesting?
Addiction Therapy
Anxiety Counseling
Art Therapy
Autism Services
Couples/Marriage Therapy
Depression
Eating Disorder
EDMR
Family Therapy
Grief & Loss
Group Therapy
Individual Therapy
Life Training
Mentoring
Nutrition Counseling
Pain Management
Play Therapy
Parenting Skills Training
Perinatal Counseling
Self Injury
School Refusal
Trauma & PTSD
Please describe symptoms or issues of concern:
Are you interested in inquiring about our graduate level intern sessions for reduced rates?
Yes
No
Non-clinical Services - these services are scheduled by their providers who will contact you directly to schedule:
Dietician – Katie Primak
Executive Functioning – Lauren Bilbrey
Insurances we accept:
Blue Cross Blue Shield PPO (All Clinicians)
Aetna (All Clinicians)
United Behavioral Health (Some Clinicians – Please Inquire)
See our
Costs and Insurance
page for details.
Insurance information - I would prefer to pay:
Using my insurance
Self-pay
If you've selected "using my insurance" please select your provider so we can match you to an available clinician:
Blue Cross Blue Shield PPO
Aetna
United Behavioral Health
How were you referred to our office?
How were you referred to our office?
Primary Care Physician
Another Therapist
Friend or Family Member
Google Web Search
Conference or Seminar
Facebook
Instagram
LinkedIn
Other
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