SCHEDULE APPOINTMENT Name of Client * First Name Last Name Name of Parent/Guardian if client is under 18 First Name Last Name Phone (###) ### #### Email * DOB of Client MM DD YYYY Message / Presenting Problem? * Method of Payment Blue Cross Blue Shield PPO Aetna USHIP (University of Chicago) Private Pay Other Insurance Member ID # If insured Insurance Group # If insured Therapy * Check all that apply: Individual Family Couples Group Psychological Testing Location * In-Person sessions available to clients who have been fully vaccinated for COVID-19 Evanston Chicago Virtual Availability Check all that apply: Monday Tuesday Wednesday Thursday Friday Saturday Please indicate any hard limit restrictions on availability Flexibility is appreciated: Thank you!
