New Client Inquiry Form

HELLO!

Please complete this form to share your current concerns and contact information. Jackie Weber, LCSW and practice owner will follow up within 48 hours of receiving this form!

If you have questions, please give us a call at (630) 402 - 6767

Today's Date

Client Name

Client's Date of Birth

Parent/Contact Name if different from client

Contact phone number

Email address

Preferred way of contact

Phone

Either

School (if a current student)

Insurance:

BCBS PPO

BCBS Blue Choice

Aetna PPO

UnitedHealthcare PPO

Self-pay

Out-of-network

Please indicate type of services you are seeking:

Individual Therapy

Group Therapy

Young Adult College and Career Transitions Group

Parenting Support

Additional information on current client concerns:

Availability for Sessions Please select all available times

Tuesday Morning

9 am - 12 pm

Tuesday Afternoon

1pm - 4 pm

Tuesday Evening

5 pm - 7 pm

Wednesday Morning

9 am - 12 pm

Wednesday Afternoon

1pm - 4 pm

Thursday Morning

9 am - 12 pm

Thursday Afternoon

1pm - 4 pm

Thursday Evening

5 pm - 7 pm

Saturday Morning

9 am - 12 pm

Additional information on client availability for appointments

Please indicate preference for in person or virtual appointments:

In-person

Virtual

I am open to either

Your information will be encrypted.

New Client Inquiry Form

HELLO!

HELLO!

Weber Therapy and Consulting, PLLC