First Name
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Last Name
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Phone
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Email
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Whom are you seeking counseling for
Self
Child
Teen
Other family member
Are you looking to work with a specific therapist or are you open to first available?
First available
Charlotte Shuber
Lydia Gedmain
Thelma Razo
Tracy Teichman
Joslyn Barajas
Emma Rooney
Briefly describe the issue you would like to work on.
What’s the best way to contact you?
Text
Email
Phone Call
What is your insurance, if you are planning on using?
Aetna
BlueCross BlueShield
Medicare
United Healthcare
I’m not planning on using my insurance.
I’m planning to use my out-of-network benefits.
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What location are needing?
Geneva
Naperville
I’m open to telehealth
Please list two days and times that you would be available for therapy sessions.
How did you hear about us?
Online Search
Psychology Today
LatinX Therapy
Therapy for LatinX
EMDRIA
Word of Mouth
Another therapist, doctor, or provider
Current or previous client
Social media
Other
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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 Creating Space Therapy therapists and/or office staff communicating with me via email or text message
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