Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Contact us
Fill out the form below and we will contact you as quickly as possible
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Preferred Name (First Name, Last Name)
*
Your answer
Phone number
Your answer
How should we reach you?
*
Via email
Via phone call during regular business hours
Via text message
Telehealth/Virtually
How can we help you?
*
Schedule a 15 minute consultation to explore treatment needs and delivery of behavioral health services
Schedule a virtual appointment for an adult age 18 and over
Schedule a virtual appointment for an adolescent 17 or under
Option 4
Other:
Required
In seeking therapy, what type of insurance do you have? I am currently in network with Aetna, Quest Behavioral Health, Carelon Behavioral Health, Anthem EAP-Bank of America & Cigna.
The following insurances companies will be accepted in September of 2025: United health Care and Blue Cross and Blue Shield of Illinois PPO.
*
Aetna
Cigna
Blue Cross Blue Shield PPO
Medicaid/Medicare
Self Pay
Other:
Let us know how you how you heard about us
*
Choose
Headway
Alma
Other
If other, please provide any other information that would be helpful to address.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
