Contact Us

Please complete the form below

Name

First Name

Last Name

Email

Phone

(###)

###

####

Have you been in individual psychotherapy before?

Yes

No

Family Counseling, Couples Counseling, Other

What brings you to therapy?

Briefly describe what presenting concerns you are looking for support with. We screen to make sure services rendered are a good clinical fit with your needs to support positive treatment outcomes. This setting is not appropriate for those needing crisis support.

Message

Let us know any specific information that would be helpful in making sure this is a good fit so that we can prioritize your time and get you the support that best suits what you need.

Payment Options

Please select if you are planning to proceed with self-pay, BCBSIL PPO plans, or if you will be using out-of-network benefits for services and require a superbill for services rendered.

Appointment Availability

When are you looking to come in? Please select a time that you would be able to commit to weekly.

Authorization to receive text, phone calls, and emails

I approve Therapy Haus to communicate via the selected modalities with regards to responding to my inquiry and rendering services.

Text

Phone Call/Voicemail

Email