Request appointment | Clearwater Counseling Chicago

Request an appointment

Please list any psychiatric medications you have taken currently or previously

If not applicable, write "None"

Limited to 600 characters

Please list any current medications including vitamins and supplements

If not applicable, write "None"

Limited to 600 characters

Please list any medical diagnoses:

Limited to 600 characters

Completing this screener is not a guarantee of services and acts as a formal request for a Consultation with an availible provider. Consultations are not the same as or equal to an intake or full clinical evaluation. The purpose of a consultation is to assess for appropriateness of fit between the potential client and the clinician. Consultations are done via phone and last an average of 10-15 minutes with a mental health provider. During this time, your answers to this form will be reviewed and additional information may be requested. Consultations are also a time for you to ask any questions about treatment expectations, confirm appointment availability, and the clinician's philosophy of care.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.