Appointment Request Form

Appointment Request Form
This form is to gather information about your needs, requests, and insurance/EAP.

This form is not intake documentation and does not guaruntee you will be offered an appointment. It does not mean you are now a client.

If your needs are outside the level of care or scope of the available providers at this clinic, or if we do not accept your insurance, we will provide you referrals to other clinics that may be able to help you.

Please note, not all providers accept all insurance plans. If no providers are accepting clients that are paneled with your insurance, you will be given referrals to other clinics who accept your insurance.
Name*

First NameLast Name
Date of birth:*
Email*
example@example.com
Appointment Preference:*

Online Appointments (Video)Only an office appointment will work for meEither an online or office appointment work for me
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
May we contact you at the email and phone number listed above?*

YesNo
What symptoms and challenges are you seeking counseling for? Please be very specific*
What past mental health diagnoses have you received, if any? If none, write N/A.*
Please check off any that apply to you. Check all that apply.*

I am currently or recently experiencing physical/domestic abuseI have urges to harm others or issues with violence towards others/animalsI have a diagnosis of personality disorder (Borderline, Antisocial, Dependent, Narcissistic). If so, please write in the diagnosis below. Please note, anxiety and depression are not personality disorders.I am seeking counseling because I am mandated by court, DCFS, or another institution.I am seeking court ordered anger management classes or PAIP classesI have been discharged from an inpatient or intensive outpatient program within the last 6 monthsI am seeking treatment as a sex offenderI am seeking treatment for my issues with abusive behavior or domestic violence towards othersI am hearing voices or seeing things but I'm not sure if these are realAddiction to gambling, pornography, sexI am experiencing an eating disorder such as anorexia, bulimia, or binge eating disorder.Anxiety, depression, or traumaADHD/ADDNone of these apply to meOther
If you checked off any of the above, please describe in more detail here (write NA if not applicable):*
Are you currently experiencing substance abuse (alcohol, marijuana, cocaine, or other drugs/substances)?*

NoYes
If you are currently experiencing substance abuse, we need more details about what you are using, how often, how much, and for how long. WRITE NA IF THIS DOES NOT APPLY TO YOU.*
Please check off any of the following that apply. If you are at risk of harm, we will provide referrals to urgent care clinics*

I have current or very recent suicidal ideation/thoughts of suicideI have current or very recent plans or urges to take my life by suicideI have a prior suicide attemptI have recently wished to be deadI have been hospitalized for psychiatric challenges prior to six months agoI am currently struggling with self-harmI have self-harmed in the pastRecently, I felt like it is easier to not be aliveNone of these!Other
If you checked off any of the above, please describe in more detail here. IF THIS SECTION DOES NOT APPLY TO YOU, WRITE NA!*
If you are in crisis, need urgent help, or may be at risk for harm, please immediately contact:

•911
•National Suicide Prevention Lifeline: Dial 988
or call 1-800-273-TALK (8255) or online chat at https://suicidepreventionlifeline.org/chat/
•Crisis Text Line: https://www.crisistextline.org/ or Text HOME to 741 741
•Northwestern/Ben Gordon 24/7 Hotline: 866.242. 0111.
•Additional community resources can be found by calling 211 or visiting: http://www.findhelp211.org/
Place of employment (if not currently employed, simply write that)*
Please put your health insurance company name here (or write self-pay if you prefer this):*
Please put Member/Policy ID number and Group Number (if there is one) for your insurance. Without this information, we cannot verify benefits. Write NA if you prefer to use self-pay.*
Please add your additional notes if you want to
After you submit this form, we may need to contact you with questions about what you wrote and we will use the phone number or email you wrote above. Please indicate your preference below regarding questions about the form, your symptoms, or anything else.*

I provide permission for you to call or email me to answer questions about my symptoms, insurance, or other questions.I provide permission to receive text messages from Life Solutions. **By checking this box you agree to receive recurring messages from Life Solutions, Reply STOP to Opt out. Reply HELP for help. Message frequency varies. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. (Please refer to our Privacy Policy At the bottom of the page for more info)Other
Please note, due to the small size of this clinic and limited resources, services for urgent/crisis issues, eating disorders, substance abuse, domestic violence, and some other challenges are not available. If you are experience challenges that no provider here can help with, we will provide referrals for you.

If you are in imminent danger or are concerned for your safety, contact 911 or go to the closest emergency room, immediately.

Additional resources:

Northwestern Medicine BGC
Address: 12 Health Services Dr, DeKalb, IL 60115
Phone: (815) 756-4875. Offers walk-in crisis assessment Monday through Friday until 5 p.m.

Call 911 if you are having an emergency or at risk of harm.

Northwestern 24/7 Crisis Hotline: 866.242. 0111

Northwestern Hospital:
1 Kish Hospital Dr, DeKalb, IL 60115
Emergency room: Open 24 hours
Phone: (815) 756-1521

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)
or online chat at https://suicidepreventionlifeline.org/chat/

Crisis Text Line: https://www.crisistextline.org/ or Text HOME to 741 741

Additional community resources can be found by calling 211 or visiting:
http://www.findhelp211.org/
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