Appointment Request Form

Step 1 of 8

Disclaimer & Important Notes
Please read through the following disclaimers and notes to better understand the appointment form and the services that are being offered.
1. Khalil Center is experiencing a rise in demand for mental health services. Khalil Center does not guarantee services upon the completion of this form.

2. Appointment Request forms can only be completed by patients or authorized legal guardians for minors. Any forms filled out on behalf of a legal adult or other family members will not be processed.

3. Khalil Center is not a crisis or trauma center. If you require immediate care, please visit your family doctor, call 9-1-1, or visit your nearest hospital emergency room. You may also call the Substance Abuse and Mental Health Services (SAMHSA) National Helpline at 1-800-662-4357 or the National Suicide Prevention Lifeline at 800-273-8255.

4. Please read through our Mental Health Services page to better understand the nature of the services offered, insurance details, and more.

5. If you are interested in psychiatric services/medication management, please visit Khalil Psychiatric Services for more information.
Consent*
I agree to the above mentioned disclaimers and notes.

Form Submission Details
Are you submitting an appointment request for yourself?*
Who are you submitting this request for?
- Child (Son, Daughter)
- Friend/Community Member
- Relative (Mother, Father, Aunt, Uncle, etc.)
Is this person legally a minor?*
- Yes
- No
Due to regulations, Khalil Center is unable to accept request forms on behalf of anyone above the legal age. Please have the individual requiring services submit a Request Form individually.
Due to regulations, Khalil Center is only able to accept forms by authorized legal guardians on behalf of minors. All other individuals are required to complete their own forms providing consent.

Location & Service Selection
Select the location you are seeking service from and the intended service.
Which Khalil Center office are you seeking services from?*
If you reside in a state other than California, New York, and Illinois, please select the "Other State" option. If you don't reside in the United States, please select the "International" option. If you reside in Canada but outside of Ontario, also select the "International" option.
Do you reside in the state of California?*
- Yes
- No
Due to licensing restrictions, California therapists are unable to provide services to clients residing outside the state of California.
This office is currently not offering individual, marital or family counseling services to new patients.
This office is currently not offering marital or family counseling services to new patients.
We are currently not offering marital, or family counseling services to new out-of-state clients.
We are currently not offering individual, marital, or family counseling services to new international clients.
Type of Service interested in:*
Psychological & immigration evaluations are NOT counseling/therapy services. Please visit our Psychological Evaluations page to learn more.
Type of Service interested in:*
Type of Service interested in:*
Type of Service interested in:*
Type of Service interested in:*
Type of Service interested in:*
Consent*
I agree to the consent policy.
Please note to schedule any appointments, the Khalil Center will need to obtain the consent of any individual who is not legally a minor and will partake in therapy.

Client Personal Info
Please fill out all the required fields as accurately as possible.
First Name*
Last Name*
Email Address*
Phone Number*
Can we leave a voicemail?
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Address*
Street Address Address Line 2 City State / Province / Region Country
Date of Birth*
Month
Day
Year
Gender*
Preferred Language for Therapy:

Spouse Information*

First Name	Last Name	Date of Birth	Email Address

Family Member Information*

First Name	Last Name	Date of Birth	Email Address

Please upload a valid government issued ID*
Drop files here or

Max. file size: 256 MB.
(State ID, Passport, Driving License, or Nexus Card)
Reasons for Services*
Briefly explain why you are seeking our services: (i.e. Depression, Anxiety, Trauma, Grief, Behavioral Problems, Future Marriage, Family Issues, etc.)

Marriage & Potential Spouse Info
Please give us the following details about your potential spouse along with your tentative marriage date to help us better understand your situation.
Potential Spouse Name*
First Last
Potential Spouse Date of Birth*
MM slash DD slash YYYY
Potential Spouse Email*
Potential Spouse Phone Number*
Tentative Marriage/Nikah Date*

If you are still undecided, please give us a range of when you expect it to happen.
Please upload potential spouse's valid government issued ID*
Drop files here or

Max. file size: 256 MB.
(State ID, Passport, Driving License, or Nexus Card)

Client Insurance Information:
Insurance:*
- Private (e.g. BlueCross, United)
- No Insurance
NOTE: Public insurance (such as Medicaid & Medicare) is only available for Lombard, IL psychiatric services.
Upload a copy of your Insurance Card
Drop files here or

Max. file size: 256 MB.
Please Specify Your Insurance*

(e.g. BlueCross BlueShield PPO, Aetna HMO)
Subscriber Name

(*If different from client)
Subscriber DOB
Month
Day
Year
ID #
Group #
Relationship to Subscriber

You have now completed all required fields for this form. Our admin team will reach out to you shortly after your submission.

Appointment Request Form

Step 1 of 8

Disclaimer & Important Notes

Form Submission Details

Location & Service Selection

Client Personal Info

Marriage & Potential Spouse Info

Client Insurance Information:

Mental Health History

Contact

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