Name*

Client Name*

Phone Number

Home Address

City

Email*

Clients Age*

Client's Insurance Provider* Blue Cross Blue Shield/Blue Choice PPOAetna PPOUnited Health Care (UHB)/UMR/Optum PPOCigna PPOOther

Location Preference (Select all that apply) WheatonNapervilleGenevaSchaumburgAny

Are you interested in online counseling? --YesNoNot Sure

For whom are you seeking counseling? --ChildAdolescentAdultMarriageFamily

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

Are you looking for Christian counseling? --YesNoNot Sure

What is the best way to contact you? --PhoneEmail

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

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