First Name *

Last Name *

Email *

Phone *

What are your preferred pronouns: *

Date of birth *

What State do you live in? *

How did you hear about us? *

Google

Instagram/Facebook

Word of Mouth

Other

Psychology Today

We offer appointments both virtually and in-person at three different locations. Which do you prefer? *

In-person at Chicago, IL Office

In-person at Crown Point, IN (Tesa only)

In-person at Mt. Prospect, IL (Liz only)

Virtual (located in Illinois & Indiana ONLY)

Note: We are only licensed to provide telehealth services to clients located in Illinois and Indiana.

Insurance *

BCBS PPO
BlueChoice PPO
Out of Network/No Insurance/Self Pay
No elements found. Consider changing the search query.
List is empty.

We are in-network with BCBS PPO and BlueChoice PPO. For all other providers, we are out-of-network, but can provide superbills for potential reimbursement. Note: We are not in-network with Medicaid (including Aetna Better Health & Blue Cross Community Health) and cannot accept Medicaid-enrolled clients. For self-pay clients, session rates range from $135-$200/session depending on the provider.

Which provider would you prefer to see? *

Liz Berland

Milo Crosswhite

Kat Boyne

Tesa Emmart (not currently accepting new patients, you will be added to a waitlist)

No preference

Please tell us a little bit about what you're looking for support with: *

Tell us a little bit about what works best for you as far as a therapist's interaction style (i.e. I'd I prefer to work with someone who is direct, offers feedback, is compassionate, nurturing, etc.) You can reference what you have liked or not liked about working with therapists in the past if applicable: *

Are you currently experiencing any of the following:* ***IMPORTANT NOTE*** This form is not a substitute for crisis support. If you are feeling unsafe, or experiencing a psychiatric emergency, please call 911 or visit your local emergency room. *

Thoughts of hurting yourself or someone else

Active substance abuse

Legal issues (arrest history, DCFS involvement, court mandated therapy, etc.)

None of the above

Please elaborate on your selection to the previous question. If you chose 'None of the above,' you can write N/A. *

I agree to the Privacy Policy provided by the company. By providing my phone number, I agree to receive text messages from the business.