Location Preference
Select your location
Full Name
*
Child's Name (if necessary)
Child's Age (if necessary)
Relationship to the child (if necessary)
Your Relationship to the Child
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?
Would you prefer a male or a female counselor?
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Choose the age of the one seeking counseling
*
Choose the age of the one seeking counseling
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 AETNA PPO, BCBS PPO, or UHC PPO and Plan On Using That Insurance?
*
Yes, I'll be using AETNA PPO
Yes, I'll be using BCBS PPO
Yes, I'll be using UHC PPO
No, I will not be using insurance.
Date of Birth of Policy Holder
Front of Insurance Card (Picture)
PNG, JPEG or JPG
Back of Insurance Card (Picture)
PNG, JPEG or JPG
Please provide a few times you are available for counseling (example: Monday's 5pm or later; 7pm would be ideal)
*
What Is the best way to contact you?
Phone
Email
Text Message
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
Submit