How may we help?

If you are experiencing a medical emergency or are in danger, please call 911 right away.

First Name *

Last Name *

Phone

Email *

How did you hear about us? *

Do you currently live in Illinois? *

Are you enrolled in a Medicaid or a Medicare Plan? *

Would you like a courtesy insurance benefits check?

Member ID

Group ID

Name of Person Using Insurance

Date of Birth of Person Using Insurance

Insurance Company's Customer Service Phone Number

Insurance Provider

Attach a clear copy of the BACK of your insurance card.

Attach a clear copy of the FRONT of your insurance card.

Do you have a specific counselor you’d prefer to work with? *

Time and Location Preferences

Please note clients with flexible schedules are often able to be seen sooner, while evening and weekend appointments tend to book up well in advance.

Do you have a preferred time of day for your appointments? *

Do you have a preferred location for your appointments? *

Please Tell Us About Your Needs *

Terms and Conditions

By checking this box, you agree to receive text messages from Summit Family Therapy regarding scheduling, appointment reminders, and important updates. Message and data rates may apply. Message frequency may vary. Reply STOP to unsubscribe or HELP for help.

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