First Name *

Last Name *

Email *

Phone *

What are your pronouns: *

How did you hear about us? *

Google

Yahoo

Word of Mouth

Other

Date of birth *

We are located at 53 W Jackson Blvd. in Chicago, IL, as well as a virtual office in Indiana and are currently offering both in-person and telehealth/video appointments. Would you prefer: *

In Person Only
Telehealth Only
Flexible
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Insurance *

BCBS PPO
Blue Choice PPO
Aetna POS/PPO (not in network)
BCBS HMO (not in network)
Cigna (not in network)
United/Optum/UMR (not in network)
Other (not in network)
Not insured
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We accept BCBS PPO, and Blue Choice PPO Plans . See our FAQ page for out-of-network info. Note: We are not in-network with Medicaid (including Aetna Better Health & Blue Cross Community Health) and cannot accept Medicaid-enrolled clients.

State

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

If you endorsed any of the above, please describe here. If you checked "none of the above" simply write n/a here. *

Messaging Consent

By providing your phone number, you agree to receive text messages from Embody + Mind Collective. Message and data rates may apply. Message frequency varies. Reply STOP to opt out.