Therapy Intake Form

1
Your Name* This field is required.
2
Email Address* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
I agree to subscribe to emails from GTWC.
YESNO
5
I agree to receive text messages from GTWC.Standard Messaging Disclosures - Message and data rates may apply. You can opt out at any time by texting “STOP.” - Message frequency may vary depending on service. - For assistance, text “HELP” or visit our Privacy Policy & SMS Terms of Service https://gracetherapyandwellnesscenter.org/privacy-policy
YESNO
6
I agree to recieve text messages from GTWC.* This field is required.Standard Messaging Disclosures - Message and data rates may apply. - You can opt out at any time by texting “STOP.” - Message frequency may vary depending on service. - For assistance, text “HELP” or visit our Privacy Policy & SMS Terms & Conditions.
YES
NO
7
What location would you prefer?
Please Select
Virtual/Telehealth
Downtown Chicago
Oak Park
Northcenter
8
What is your availability for your weekly appointments?
9
How will you be paying for services?Please select the option that best reflects your current plan. Our intake team will review your information and follow up with next steps. Note: GTWC is not in-network with HMO plans.
Please Select
BCBS / Anthem PPO
Aetna PPO
Humana PPO
Cigna/Evernorth PPO
UnitedHealthcare / Optum PPO
Medicaid – BCBS Community
Medicaid – CountyCare
Medicaid – Molina
Medicaid – Meridian
Self-Pay
Sliding Scale (starting at $90 per session)
Low‑Cost Sliding Scale (with a clinician‑in‑training)
10
What modality of therapy are you looking for?
Individual Therapy
Couples Therapy
Family Therapy
Group Therapy
11
Therapist Gender Preference
Male
Female
Non-binary
No preference
12
Tell us a little about yourself and how we may best be of service* This field is required.
13
Do you have any additional preferences in regard to your therapist?
14
How did you hear about us?
Google Search
Clicked on Google Ad
Insurance Website
Other service provider
15
I agree with the privacy policy.* This field is required.
YESNO
Should be Empty: