If you are interested in becoming a new client, or seeking information about our therapy services for yourself or a loved one please fill out the form below. Our intake coordinator will reach out to you and answer any questions that you may have and help you find the right therapist to meet your needs. Please select the inquiry form that best describes the kind of referral you are seeking.

New Child Client Inquiry Form

Name *

Name of parent or guardian filling out this form

First Name

Last Name

Phone *

Parent or Guardian Phone

(###)

###

####

Email *

Parent or Guardian Email

Why is your child seeking therapy? *

Briefly describe what issues you are hoping your child will address in therapy.

Client Name *

Name of child seeking counseling

First Name

Last Name

Client Age *

Client Availability *

Please include days & times

Session Preference *

In-person

Telehealth (Zoom)

Either

Insurance Coverage *

Blue Cross Blue Shield PPO

BCBS Choice Plus

Aetna Behavioral Health

Out-of-network

Thank you for reaching out!

Our intake department will be in touch with you shortly, usually the same day for forms filled out before 2:00 pm and usually the next business day for forms filled out after 2:00 pm.

New Adolescent Client Inquiry Form 3

Name *

Name of parent or guardian filling out this form

First Name

Last Name

Phone *

Parent or Guardian Phone

(###)

###

####

Email *

Parent or Guardian Email

Why is your adolescent seeking therapy? *

Briefly describe what issues you are hoping your adolescent will address in therapy.

Client Name *

Name of adolescent seeking counseling

First Name

Last Name

Client Email *

Adolescents age 12-17 must have an email address on file for completion of paperwork

Client Age *

Client Availability *

Please include days & times

Session Preference *

In-person

Telehealth (Zoom)

Either

Insurance Coverage *

Blue Cross Blue Shield PPO

BCBS Choice Plus

Aetna Behavioral Health

Out-of-network

Thank you for reaching out!

Our intake department will be in touch with you shortly, usually the same day for forms filled out before 2:00 pm and usually the next business day for forms filled out after 2:00 pm.

New Couples Client Inquiry Form

Client Name *

Name of person seeking counseling

First Name

Last Name

Phone *

(###)

###

####

Email *

Why are you seeking therapy? *

Please tell us a little bit about which marital or relationship issues you are seeking to address in therapy.

Client Availability *

Please include days & times

Session Preference *

In-person

Telehealth (Zoom)

Either

Insurance Coverage *

Blue Cross Blue Shield PPO

BCBS Choice Plus

Aetna Behavioral Health

Out-of-network

Thank you for reaching out!

Our intake department will be in touch with you shortly, usually the same day for forms filled out before 2:00 pm and usually the next business day for forms filled out after 2:00 pm.

New Adult Client Inquiry Form 2 2

Client Name *

Name of person seeking counseling

First Name

Last Name

Phone *

(###)

###

####

Email *

Why are you seeking therapy? *

Client Age *

Client Availability *

Please include days & times

Session Preference *

In-person

Telehealth (Zoom)

Either

Insurance Coverage *

Blue Cross Blue Shield PPO

BCBS Choice Plus

Aetna Behavioral Health

Out-of-network

Thank you for reaching out!

Our intake department will be in touch with you shortly, usually the same day for forms filled out before 2:00 pm and usually the next business day for forms filled out after 2:00 pm.

3633 W Lake Ave, Ste 300
Glenview, IL 60026

Phone

847-699-2490

Email (for general inquiries)

info@glenviewcounseling.com

Email (for new clients)

intake@glenviewcounseling.com

3633 W Lake Ave, Ste 300, Glenview , IL 60026

847-699-2490
intake@glenviewcounseling.com

For Clinicians

Contact Us

Contact Info & Form + map

New Client Inquiry Form

3633 W Lake Ave, Ste 300Glenview, IL 60026

3633 W Lake Ave, Ste 300
Glenview, IL 60026