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Transcend Counseling Chicago: New Therapy Client Inquiry
Thank you for your interest in working with us here at Transcend Counseling Chicago! Your responses on this form will be kept strictly confidential.
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* Indicates required question
Email
*
Your email
Client's legal first and last name
*
Your answer
Clients preferred name (if different from legal name or not the person filling out this from)
Your answer
If seeking couples counseling: Partner's name
Your answer
Client's Age(s)
*
Your answer
Phone Number
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Your answer
May we leave a message at the above phone number?
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Yes
No
What kind of insurance plan do you have? (Please note, we are NOT in-network for BCBS Medicaid/Medicare/HMO plans nor Aetna Better Health.)
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BlueCross BlueShield of Illinois (BCBSIL) (PPO or Blue Choice Options PPO)
Cigna/Evernorth
Aetna (not Aetna Better Health)
United Healthcare/Optum/Student Resources
UIC CampusCare (Must have authorization from doctor before starting services)
Self- Pay
What services are you looking for?
*
Adult Individual counseling
Couples/ romantic partners counseling
Child or adolescent counseling
Psychological testing
Gender affirming surgery assessment
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