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Please note that this form is not to be used for emergencies; if you’re experiencing a major problem, please proceed to the nearest hospital emergency room or call 911. All inquires will receive a response within 24 hours.

Name (required)


City, State, Zip

Telephone Number

Email (required)

Client's Age (required)

Would you prefer to see a therapist in Wheaton, Naperville, Geneva, or Schaumburg?

For whom are you seeking counseling?

When are you generally available to come in for therapy? (click all that apply - required)
Weekday MorningWeekday AfternoonWeekday EveningSaturday MorningSaturday Afternoon

Are you looking for Christian counseling?

What is the best way to contact you?

Please describe the issue you would like to work on so that we can find the most appropriate therapist.

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