First Name*

Last Name*

Preferred or Chosen Name (Optional)

Pronouns (Optional)

To support you in connecting with a culturally responsive therapist, please share your racial, ethnic, and/or cultural background (Optional)

Email*

Phone Number*

How Did You Learn About Us?
Internet SearchTherapy for Black GirlsTherapy for Black MenInclusive TherapistsPsychology TodayFamily or FriendPhysicianOther

If 'Other', Please Specify:

Preferred Therapist*
—Please choose an option—Masuma Rasheed, PhDAlex Ngo, LCSWMalarie Marquez, LPCNoah-Christina Reed, LCPCErika Chavez, LCSWLuz Maria Miranda, LCPCTiffani Clay, LCPCSophia Ou, LPCSylvia Chen, LCSWNui Waris, LPCKatie Hatches, LPCMellany de Medeiros Nones, LCPCAbby Fuentes, LSWMiranda Mihalic, LSWNo Preference

Insurance*
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If 'Other' Insurance, Please Specify:

Name on Insurance Card*

Date of Birth for Name on Insurance Card*

Insurance Member ID #*

Acknowledgment: Illinois Services*
I acknowledge that I am seeking services while in the state of Illinois.

Acknowledgment: Telehealth Services*
I acknowledge that Mindful Life Counseling provides services exclusively through telehealth. I understand that all sessions will be conducted remotely, using telecommunications technology, and I consent to receiving services in this format.

What issues are you hoping to address in therapy?*

What days/times work best for you?*

Is there anything else you'd like to share?

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