Request an Appointment / Make a Referral
Please fill out the following information.  We will check your benefits and connect you with a therapist.  

An email response for all requests and inquiries will come to you from a member of our intake team at info@mindbodycoopchicago.com within 24 hours. If you do not receive an email response during that time frame, please check your spam and/or junk mail folders. If we do not hear back from you within a week, we will then call the number you supplied.  
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Email *
First Name: *
Last Name: *
Living Name (if different than legal name above):
Pronouns:
Age: *
Phone Number: *
Can we call or text you? *
Can we email you? *
Preferred Language: *
If you are seeking services that are provided by Licensed Clinical Professional Counselors, Licensed Clinical Social Workers or Psychiatric Nurse Practitioners, please check the box confirming that you live in Illinois. Do you currently reside in Illinois? *
Required
If you are seeking services that are provided by Registered Dietician, please check the box confirming that you live in Illinois or Minnesota . Do you currently reside in Illinois? *
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Current Zip Code *
Individual Healing Options:
Specialized Healing Options:
If interested in Psychotherapy, and if comfortable, can you please share your current support needs?
Can you please confirm if you have had psychological hospitalization in the past six months? *
Group Healing Options:
Insurance Provider
Mind Body Co-op is In-Network for the following providers.  Please indicate your provider below. For out of netwrork providers, we are happy to file an out of network claim for you or give you a superbill that you can submit to your insurance for reimbursement.
I have the following PPO Insurance Provider (we do not accept HMO or Medicaid policies and are currently not accepting new patients with  Optum or United behavioral health): *
Mind Body Co-op has some availability to see fully vaccinated clients in the office at 30 N. Michigan. Please indicate if you prefer in-person or telehealth sessions. *
Preferred Day of the Week: *
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Ideal Time of Day (Please choose at least 3 options): *
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I am interested meeting with a specific clinician (see bios on the website): *
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How Did You Hear About Mind Body Co-op? *
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We love to say Thank You. If you received our name from a healthcare provider or a school counseling center, please enter their name below. Don't worry, we will not give them your name. *
In connection with the previous question, can you please include the email address for the healthcare provider or school counseling center, if available? Again, don't worry, we will not give them your name. (If not available, feel free to list N/A): *
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