Appointment Request for The Center for Modern Relationships
Hello and thank you for your interest in working with our practice!

Complete our confidential form below and we will connect you with a relationship and sex therapist on our team. We will be in touch within 48 business hours to provide you with appointment availability. From there, you will be able to schedule a clinical consultation call directly with one of our clinicians. If you have any questions, please reach out to intake@cmrchicago.com. NOTE: Please check your spam folder for our initial email.

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Email *
Email *
Name

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What are your pronouns? (she/her, they/them, he/him, etc.)
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Phone number
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Date of birth
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Are you looking for relationship therapy or individual therapy?
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Required
We are located at 1300 W. Belmont Ave. in Chicago, IL and are currently offering both in-person and telehealth/video appointments. Would you prefer:
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What state are you located in?

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Please tell us a little bit about what you're looking for support with:

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Tell us a little bit about what works best for you as far as a therapist's interaction style (i.e. I'd I prefer to work with someone who is direct, offers feedback, is compassionate, nurturing, etc.) You can reference what you have liked or not liked about working with therapists in the past if applicable:
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How did you hear about our practice?  *
Are you currently experiencing any of the following:*
***IMPORTANT NOTE*** This form is not a substitute for crisis support. If you are feeling unsafe, or experiencing a psychiatric emergency, please call 911 or visit your local emergency room.
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If you endorsed any of the above, please describe here. If you checked "none of the above" simply write n/a here.
What days and times are you consistently available for a weekly appointment? **Note: Evening and weekend appointments are limited. Please provide multiple options you're available if possible.**  *
The Center for Modern Relationships is an in-network provider with Blue Cross Blue Shield PPO. Please indicate if you have a BCBS PPO policy, or if you'll be self pay. Note: We are not in-network with BCBS Blue Choice plans or HMO plans.  *
A copy of your responses will be emailed to the address you provided.
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