Location Preference

Select your location

Geneva
Hinsdale
Telehealth
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Full Name *

Child's Name (if necessary)

Child's Age (if necessary)

Relationship to the child (if necessary)

Your Relationship to the Child

Parent
Guardian
Other
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Phone *

Email *

Address *

City *

State *

Postal code *

Due to state licensing restrictions, we are only allowed to serve Illinois residents.

Whom are you seeking counseling for? *

Whom Are You Seeking Counseling For?

Myself
Child / Teen
Parent/Guardian
Family
Couples
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Would you prefer a male or a female counselor?

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Female
Male
No preference
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Choose the age of the one seeking counseling *

Choose the age of the one seeking counseling

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19-25
26-39
40-50
51-60
61-70+
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How would you like to receive services?

In-Person Only

Telehealth Only

Open to Both

Insurance Verification (If you plan to utilize your insurance)

Do You Have BCBS PPO and Plan On Using That Insurance? *

Yes

Date of Birth of Policy Holder

Front of Insurance Card (Picture)

Back of Insurance Card (Picture)

Please provide a few times you are available for counseling (example: Monday's after 5pm; 7pm would be ideal) *

What Is the best way to contact you?

Phone

Text Message

Would you like to receive our best relationship advice sent to your email?

Yes

How did you hear about us? *

Briefly describe the issue(s) you would like us to work on

Email and SMS Text Message Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Cedar Tree Counseling therapists and/or office staff communicating with me via email or text message