New Client Interest Form - The Vita Collective with Julia Hogan-Werner, LCPC, ACS

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Please provide the information below to work with Julia Hogan-Werner, LCPC, ACS. We will be in touch as soon as an opening becomes available.

First Name *

Last Name *

Date Of Birth *

YYYY

Email *

Phone Number *

I am interested in:

Individual Therapy

Intensives

Group Therapy

Clear selection

Please provide a brief description of why you are seeking support at this time?

In Person vs. Telehealth (For Telehealth sessions, you must be present in the state that your therapist is licensed to practice in. If you are traveling or moving out of state for the session, please notify your therapist on the next best steps)

In Person Sessions Preferred (O'Hare Office)

Telehealth Sessions Preferred

No Preference

Clear selection

Time Preference (Please select all times that apply)

Tuesday/Wednesday Morning

Tuesday/Wednesday Afternoon

Tuesday/Wednesday Evening

Would you like to hear about openings outside of your preferred times? (Evening openings are limited and you may be added to the waitlist).

Yes

Clear selection

How did you hear about us? *

Submit

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