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New Client Appointment Request

Please fill out the following form to help us understand how we can best serve you.

Client First Name

Last Name

Guardian First Name (if applicable)

Email Address

Phone

Insurance Provider or Self-Pay

What is your appointment availability?

Open availability

Daytime preferred

Evening preferred

Weekend preferred

What is the age of the client?

Session Preference:

In Office-Chicago

In Office-Woodstock

In Office-Crystal Lake (under 22 yo)

Telehealth Video

Anything else we need to know?

Thank you! We will contact you in 1 business day.

Next Level Counseling and Wellness

Info@NLWell.org

Phone: (815) 575-8860

Fax: (815) 668-8955

Woodstock

226 W. Judd Street, Suite C.

Woodstock, IL 60098

Chicago

3525 W. Peterson Ave, Suite 607

Chicago, IL 60659

Crystal Lake

44 N. Virginia St, Suite 2B

Crystal Lake, IL 60014

©2019 by Next Level Counseling and Wellness.