Full Name *

Email *

Phone *

Address *

City *

State *

Postal code *

What type of services are you looking for? *

Relationship to the Child

Due to state licensing restrictions, we are only allowed to provide therapeutic services to Illinois residents

For whom are you seeking counseling? *

Would you prefer a male or female counselor? *

What is the age of the one seeking counseling?

How would you like to receive services? *

Insurance Verification (if you plan to utilize your insurance)

Read more about our Insurance Policy

Name of your insurance policy *

Name of policy holder *

Date of birth of policy holder *

Front of the Card (Picture) *

Back of the Card (Picture) *

Please provide at least 3 times you are available for counseling *

Example: Monday after school (3:30pm - 7) would be ideal, Saturdays 9-11,. Wednesday evenings (5-8) Friday mornings

What is the best way to contact you? *

Phone

Text

Would you like to receive our best counseling and relationship advice sent to your email address? *

Yes

How Did You Hear About Us? *

Briefly describe the issue(s) you would like to work on *

Also mention any therapist you think would be a good fit

I understand that the use of my email and SMS text messages are inherently secure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Ammirati Counseling Group therapist and/or office staff communication with me via email.

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