Intake Request FormFill out the form below, and our intake team will be in touch soon with therapist matches tailored to you. Name * First Name Last Name Pronouns (optional) Email * Phone Number (Optional) (###) ### #### Date of Birth * MM DD YYYY What type of therapy are you pursuing? * Individual Therapy for Minor Individual Therapy for Adult Relationship Counseling Family Counseling What are you hoping to address in therapy? * Therapist preferences How do you plan on paying for services? * In-network Insurance (BCBS PPO, Blue Choice PPO, United / Optum, Northwestern University student Aetna) Full-fee - $150 / session Out of network insurance ($150 / session) Sliding Scale Thank you!
