Online Appointment Request

Appointment Request – Chicago Mental Health Services

Open Avenue – (312) 344-3184
*Insurance Verification Form

Request a session with one of our therapists. Let us know what time you’re available and what you’re hoping to gain from therapy.

    Name*

    Phone Number*

    Client Email*

    Select Therapist - 1st Choice*

    Select Therapist - 2nd Choice*

    First Choice Date/Time*

    Second Choice Date/Time*

    Have you been to therapy before?*

    Anticipated length of treatment?*

    Reason(s) for seeking therapy. What are you hoping to gain?*

    File Upload (if needed)

     

    *Note: If you intend on using insurance for treatment you must fill out the insurance verification form at least 48hrs in advance of your scheduled appointment.