Psychiatric Services Request
Enter your information below in order to request an evaluation from CCC's NP for evaluation and medication management. We will utilize this form to assist in scheduling when services are available.
Please note this is not constantly monitored and any crisis needs should be directed to 911 or your nearest emergency room.
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BCBS HMO (write HMO provider in "Other")
BCBS Community (Medicaid)
Current Therapy Provider
Clearwater Counseling Chicago Therapist
I have a therapist at another practice (enter their information in "Additional Comments")
I am not currently in therapy
Reason for Requesting Psychiatric Evaluation/Medication Management:
As soon as available
Within the next month
Are you currently on any psychotropic medications? If so, who prescribed them?
Yes- Please put prescriber's information in "other."
Completing this form is not a guarantee of services. Within 72 hours of submission, you will receive an email from a CCC staff member with next steps. Please be mindful to check your junk mail folder.
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This form was created inside of Clearwater Counseling Chicago.