New Client Form
After you complete this new client form, we will contact you within 24 business hours to schedule an appointment. If you have any questions or concerns, please contact us at 847-400-0078 or
. Thank you and we look forward to working with you!
Preferred contact method
About what service are you inquiring?
Executive Functioning Coaching
Active Therapy/ Movement Therapy (fitness, yoga, walk and talk)
Your name and name of the patient (if different)
What is the age and gender of the patient? Please note if there is a preference for clinician gender.
Please enter the product number
At True Mind and Body, some of our clinicians are paneled with Blue Cross Blue Shield of Illinois (PPO only). All other clinicians are private pay (out of network). Please let us know if you would prefer a BCBS clinician. *Note: we will provide monthly invoices for out of network reimbursement. Check with your insurance plan to determine your out of network coverage.
I have BCBS PPO and would like a BCBS provider.
I have BCBS PPO and am fine with either BCBS or Private Pay, based on fit of clinician and me/my child. I understand I will be paying out of pocket if I choose an out of network provider.
I do not have BCBS PPO and understand I will be paying out of pocket.
Please briefly tell us about your goals for treatment.
How did you hear about True Mind + Body? ( If physician, please list name).
Questions and comments
Send me a copy of my responses.
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