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Online Request Form

Online Request Form2023-06-26T14:18:53-05:00

Thank you for making us your trusted partner on your mental wellness journey! Please complete this form in its entirety. Upon receipt, we will call or text you to confirm we’ve created a client portal, and you will receive an email invitation to set up your portal. In your portal, please complete all the intake forms (consents, assessment(s) and biography). When your intake packet is complete, we will be in touch as soon possible to schedule you with a clinician.

Preferred Language

Client Name *

First

Last

Date of Birth *

Parent or Guardian Name

(if client is younger than 18)

Relationship to Client

Email *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Method of Contact *

Call
Text
Email

Please select all that apply

How did you hear about us? *

You're a former client
Referred by a friend/colleague/former client
Online search
Social Media
Insurance
Doctor (please note name/contact below)
School (please note name/contact below)

If referred from a doctor or school; please indicate person's name and contact information (email/phone)

Preferred Language for Services *

Race *

Ethnicity *

Gender *

(Optional) Specify, Other/Transgender, etc.

Pronouns

Household Size *

Please note how many people live in your current household

Household Income *

This information is kept confidential and does not influence your ability to seek services or use insurance. This information is gathered for the purpose of client's needing financial support for services and/or grant funding as a not-for-profit agency.

Insurance OR Payment

YFC will check your benefits.

Will you need assistance to afford counseling?

Yes
No
Not sure

Insurance Carrier *

Other Insurance

Member ID *

Group ID

Reason(s) for Seeking Services *

Emotional Distress (such as anger, anxiety, depression or self-esteem)
Significant Life Events (such as abuse, trauma, death, grief, divorce, illness/injury)
Behavioral concerns (alcohol/drug use, oppositional/defiant behaviors, attention/impulse, self-harm)
Relationship stress (parent/child, couples, family stress, parenting challenges)
None of the above (details noted below)

Select all that apply

Additional Notes about reason for seeking services

Is there anything else you would like us to know about why you're seeking services for yourself/child?

Libertyville

1113 S. Milwaukee Avenue, #104
Libertyville, IL 60048

Gurnee

5101 Washington Street, Suite 2-F
Gurnee, IL 60031
(Saratoga Square mall)

Lake Zurich

47 Church Street
Lake Zurich, IL 60047
(St. Peter United Church of Christ)

Phone: (847) 367-5991
Fax: (847) 367-5997

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