Schedule an Appointment

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*

    Client Name*

    Phone Number

    Home Address

    City

    Email*

    Client's Age*

    Client's Insurance Provider*

    BCBSAetnaUBG/OptumCignaOther

    Location Preference (Select all that apply)

    WheatonNapervilleGenevaSchaumburgAny

    Are you interested in online counseling?

    For whom are you seeking counseling?

    Would you prefer male or female counselor?

    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?

    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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