New Client Appointment Request

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

First Name

Last Name

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 range of the interested individual?

Under 12 years old

12-17 years old

18-25 years old

25-65 years old

Couple/Family

Session Preference:

In Office-Chicago

In Office-Woodstock

Telehealth Video

Anything else we need to know?

Thank you for contacting us. We will be in touch within 1 business day.

(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