Contact Form

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Contact Form

For inquiries and to schedule a free 15-minute phone consultation with Dr. Ariel, please reach out by completing the form below. Dr. Ariel will get back to you within 1-2 business days.

If you are interested in scheduling an Intake Appointment with Dr. Ariel, please complete the Intake Request Form.

This form should not be used in emergencies. If you are experiencing a medical or psychiatric emergency, please call 911 or visit your nearest emergency room.

Email *

Name (First and Last) *

Phone Number *

Please select one of the choices below: *

I reside in Illinois.

I reside in a state that is participating in PSYPACT (https://psypact.org/mpage/psypactmap). Please indicate your state of residence in the text area below.

Required

My primary reason for seeking therapy is... (include PSYPACT state if applicable): *

I understand that Dr. Ariel is an Out of Network Provider for all insurance companies. (See additional information under the Fees and FAQ page). I would like to: *

Utilize my Out of Network benefits (Superbill request: seeking potential reimbursement from my insurance company)

Self-Pay (No superbill request)

Required

How did you hear about me? *

Availability for 15-minute Phone Consultation: (Please include preferred times/dates in CST):

(If you are not requesting to schedule a consultation, please type "N/A").

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This form was created inside of Reflect Psychological Services, PLLC.