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) *

Important: When are you available for appointments?

First and second doctor preference:

Or I would like the Administrative Director to select an appropriate staff person for me based on availability and experience with my/our situation.

Name of your health insurance plan(s)

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' )

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