Contact The Psychology Center | Chicago, Illinois 60643

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Additional Preferences

in office visits
online telepsych sessions
either one is ok

For an evaluation, please describe:

Name *

Phone *

Okay to text?

OK to Leave Voice Mail?

Confidential Fax

Email *

Mailing Address (Please include full address with city and zip code) *

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about us or decide to chose our office?

How do you wish to pay for your treatment ? We accept:

Self-pay by cash, check, or credit card - including monthly plans
An eligible health insurance plan which our office accepts

Important: When are you available for appointments?

First and second doctor preference, if any:

Or would you like the Administrative Director to select an appropriate staff person for you based on availability or experience with your situation?

Select the items that apply, and then let us know how to contact you.

Send literature about your private practice and a business card
Have a staff Doctor contact me right away by telephone, email or text.
Mail or email forms to me so I can register as a new client (or you can print out these forms now by going to "Client Forms' under 'Get Started' )

Your Questions or Comments Please

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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