Waitlist Request Form
Client's First Name
*
Client's Last Name
*
Client’s DOB
*
Parent/Guardian Name
Phone
*
Email
*
What type of counseling are you seeking?
Individual - Adult
Individual - Minor
Couples
Family
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If Couples, please share your partner's name, DOB, and email address.
Insurance Type
Location Preference (You may select more than one)
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Woodstock
Lake in the Hills
Elgin
Telehealth
First available
Please provide a timeframe you are available for counseling
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Please share your preference on who you would like to see
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Briefly Describe The Issue You Would Like to Work On
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Email Risk Acknowledgement and Use Consent
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I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Pivotal Counseling Center therapists and/or office staff communicating with me via email or text message
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