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

Have you received services at Life Solutions before?

Appointment Preference:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

May we contact you at the email and phone number listed above?

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.

You indicated that one or more of the above applies to you. Please provide additional information about what you selected so we can better understand your current needs.

You indicated that you have been diagnosed with a personality disorder. Please tell us what diagnosis you received and approximately when you were diagnosed? *Please include any additional information you feel would be helpful for us to know.

You indicated that you are experiencing concerns related to an eating disorder. Please provide more information about what you are currently experiencing, including any diagnosis you have received, how long this has been a concern, and whether you are currently receiving or have previously received treatment for it.

You indicated that you are seeking services related to an addiction, such as gambling, pornography, or another compulsive behavior. Please describe the specific concern, how long it has been a concern, and how it is currently affecting your daily life.*

You indicated that you are seeking court-mandated services. Please provide more information about the services you are required to complete, including the reason for the requirement and the type of service, evaluation, or documentation being requested.*

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)?

You indicated that you are currently experiencing substance use concerns. We need more details about what you are using, how often, how much, and for how long.

Please check off any of the following that apply. If you are at risk of harm, we will provide referrals to urgent care clinics

You indicated that one or more of the above applies to you. Please provide additional information about what you selected so we can better understand your current needs

You indicated that you have a history of a suicide attempt. Please provide approximately when this happened and any additional information you feel is important for us to know.*

Are you currently taking any psychotropic medications? If yes, please list them.

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

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.

Other

The Telephone Consumer Protection Act (TCPA) prohibits a person or company from making any call using any automatic telephone dialing system or an artificial or prerecorded voice to any wireless telephone number unless the call is made for an emergency purpose or the call is made with the prior express consent of the called party. Through this Prior Express Consent, I consent to allow Life Solutions to contact me through automated technology at my mobile phone. I agree to allow Life Solutions to contact me regarding products or services related to my medical care. I understand that my medical care is not conditioned on my acceptance of this Prior Express Consent.

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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