Grace Integrated Intake Form
Welcome!  Thank you for taking the time to complete this form thoroughly, including insurance information, as that will reduce your wait time to be paired with the right clinician.  We value your privacy and the only individuals who have access to this form are those who will be helping you get started on your therapeutic journey.  Once you have completed the form a scheduling coordinator will be in contact within 7 business days.  You can also follow up via email at 
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Email *
Name of Person Completing this Form: *
Name of Client (if different from above) or NA: *
Client date of birth: *
Phone: *
Can a Voicemail be left on the phone number provided: *
Private Email Address that can be used for Follow Up: *
Preferred method of communication: *
Zip code (for insurance verification) *
Insurance Carrier Name - (For HMO plans, include the site affiliation (AMITA, Duly, Loyola, RUSH, etc.))  Or Identify as Self-Pay. *
Insurance Member ID and Group Number (of client): *
Is this an HMO or PPO policy *
Identify your top 3 choices in order of preference:
First Choice
Second Choice
Third Choice
Riverside In-Person limited availability
Oak Brook In-Person
Westmont In-Person
Lombard In-Person
Any Location - First Opening As Priority
Clear selection
Availability for ongoing therapy appointments (select all that apply): *
Male or Female clinician preferred: *
Clinician Specialty (examples such as couples, individual, christianing, parenting, Spanish speaking, anxiety, depression, etc.): *
Referred by (if you have a doctor's referral, please include your doctor's name):
Reason for requested counseling at this time, please be as detailed as you can: *
Have you been seen by a mental health professional before? *
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