Schedule an Appointment We are here to assist you Please complete this form so we may better serve you: Schedule an Appointment Full Name of Person to Receive Services * Name of Parent or Legal Guardian (If a minor under age 18 or an adult who has a legal guardian) Date of Birth * Phone Numbers Land Line Cell Phone Cell Email Address * Services Desired (select as many as appropriate) * Counseling/Therapy Developmental Disabilities Psychiatric Substance Use Vocational Parents as Teachers - Birth to Three OtherOther Scheduling Preferences Day(s) of the Week: * Monday Tuesday Wednesday Thursday Friday Time of Day: * AM (8AM - Noon) PM (Noon - 5PM) Evening (5PM - 8PM) Do you reside in Illinois? * Yes No Payment Type * Illinois Medicaid Medicare Private Insurance Self Pay Name of Insurance Provider Questions: (please do not provide personal/confidential information) You can expect a reply the next business day. If you need to talk to someone right away, please call our crisis line at 217-222-1166 anytime. Submit If you are human, leave this field blank.
