Important Information for Completing This Form

This form is intended for legal guardians, including parents, of minors or dependents under guardianship seeking mental health services. Please review the following information carefully before completing the form:

1. For Parents/Guardians Only: This form is specifically for legal guardians, including parents, filling out information on behalf of a minor child or dependent under guardianship who is requesting mental health services. In the State of Illinois, individuals aged 12 or older may seek mental health services independently, without a guardian. Therefore, if you wish to be involved in their care, you may complete this form, and we will also need a completed and signed release of information form from the individual. We can assist in obtaining this release if needed.

2. Mental Health Psychotherapy Only: Please note that our services are limited to mental health psychotherapy; we do not offer medication management at this time.

3. Answering Questions: If you encounter any questions that you cannot answer, please type “N/A” in the response field to proceed.

4. Accepted Insurance Plans: For a list of insurances we accept, [click here]

5. Additional Forms:

   • For individuals seeking services independently, without the assistance of a guardian, [click here for the self-advocate form].

   • For couples seeking services, [click here for the couples form].

Thank you for your cooperation. We look forward to providing the necessary support.