Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred method of communication *

Phone

Email

Text

Type of Support *

Which type or types of therapy are you interested in?

Individual Therapy

Family Therapy

Couples Counseling

Unsure

Availability *

When are you normally free for an appointment? Choose all that apply.

Flexible

Weekdays

Weekends

Evenings

Are you covered by Blue Cross/Blue Shield PPO? *

Introspective Family Therapy only accepts BCBSIL PPO/Choice PPO insurance at this time.

Yes

No

Have you seen a therapist before? *

Yes

No

If we currently have a waitlist, would you like to be added to it? *

Yes

No