New Client Service Form
Please complete this form to inquire about beginning therapy services. You can also complete this form if you are interested in social work supervision or mentorship. You will receive a follow up within 48 business hours from your submission.
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Email *
What is your first and last name? *
What is your preferred name?
What is your contact information? Phone number and email. *
What is the best way to reach you? *
What is your date of birth? *
MM
/
DD
/
YYYY
Gender - as identified by insurance? *
Self identified gender
Do you reside in Illinois? *
What services are you interested in? *
Required
What is your form of payment for services? *
What are you hoping to work through or work on in therapy? *
Please provide what you would like to work on in therapy. Examples can be if you feel you struggle with anxiety, depression, anger, low self esteem, and so on.
Have you ever seen a therapist before?
 *
How did you hear about our practice?
 *
Required
Please provide your availability.
 *
Please check off any and all of your availability.
Required
Are you okay with your session being held virtually? (At this time all sessions are virtual. In person sessions will be available late 2026) *
How often would you like to have sessions? *
Is there anything you would like me to know at this time?
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