Appointment Request Form

Step 1 of 4

Are you submitting an appointment request for yourself?*
Who are you submitting the request for?*
Is this person legally a minor?*
- Yes
- No
If you reside out of state from one of our physical office locations ie: NYC, CA, Toronto , or IL, our therapists can only offer a limited number of coaching sessions. Please also note that if you register you may expect a current wait time due to high demand in services. In Sha Allah, our admin team will respond once you have filled out the request form.
Due to regulations, Khalil Center is unable to accept request forms on behalf of family members or friends above the legal age. Please have the individual requiring services submit a Request Form individually. If you would like to consult with a clinician regarding a family member or friend, please fill out a Request Form with your individual information. If you have any questions, please email info@khalilcenter.com

First Name*
Last Name*
What Kind of Service are you Seeking Today?*
- In Person Therapy
- Web Therapy
During COVID-19 we will only be offering web therapy.
Which Khalil Center office are you seeking services from?*
If you reside outside California, New York, Illinois, or Canada, please choose the "Other" option.
Consent*
I agree to the consent policy.
Please note to schedule any appointments, the Khalil Center will need to obtain the consent of the listed family member(s) who will partake in therapy.
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.
State of Residence*
Type of Service interested in:*

*
Spouse's First Name Spouse's Last Name Spouse's Date of Birth Spouse's Email Address

*
Potential Spouse's First Name Potential Spouse's Last Name Potential Spouse's Date of Birth Potential Spouse's Email Address

*
Family Member's First Name Family Member's Last Name Family Member's Date of Birth Family Member's Email Address

Reasons for Services*
Please describe in detail: (i.e. Depression, Anxiety, Trauma, Grief, Behavioral Problems, Medical/Health Concerns, etc)
Email*
Phone*
Can we leave a voicemail?

Yes

No
Can we communicate via SMS?

Yes

No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Month
Day
Year
Gender*
Preferred Language for Therapy:

Client Insurance Information:
Insurance:*

Private (e.g. BlueCross, United)

Public (e.g. Medicaid, Medical, Medicare)

No Insurance
Public insurance is only for Lombard,IL psychiatric services only.
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

Please upload a valid government issued ID copy of ALL adult family members seeking therapy services.*

Drop files here or

Max. file size: 256 MB.

Please upload a copy of your valid government issued ID. (State ID, Passport, Driving License, or Nexus Card)*
Max. file size: 256 MB.
Please upload a copy of your spouse's/partner's valid government issued ID. (State ID, Passport, Driving License, or Nexus Card)*
Max. file size: 256 MB.

Mental Health History
The next set of questions may be difficult to answer. Please take your time while we go through these.
Have you ever been given a psychiatric diagnosis?*

Yes

No

Unsure or cannot recall
If yes, please describe and include if the diagnosis is still active and when it was first given.
Have you ever had any counseling or psychological services?*

Yes

No
If yes, please state the name of the clinic/office the services were received, the therapist(s) who counseled you, and the reason for treatment and termination of treatment.
Did you ever or do you currently take any medication(s) for any psychiatric reasons? If so, please list them below.*
Have you ever been hospitalized due to psychiatric or substance use reasons?*

Yes

No
If so, when was the most recent hospitalization?

Less than 30 days ago

Less than 6 months ago

Less than 1 year ago

More than 1 year ago
Please describe the cause(s) of the hospitalization.
Do you think you have a problem with alcohol or drugs?*

Yes

No
If yes, what substances and how do you use them?
When, where, and in what situations are you most likely to use?
Do you smoke? If so, how often?*

Never

Rarely

Frequently

Daily
Have you used drugs other than those required for medical reasons?*

Yes

No

Occasionally

Other/Web (Please complete the questions below)
Have you ever been in a treatment program for substance use?*

Yes

No
Have you ever had thoughts of suicide?*

No

Yes, in the past

Yes, recently
If in the past, to your best knowledge, when was the last date of ideation?
MM slash DD slash YYYY

Please explain the cause(s) of ideation as well.
If recently, do you have a plan?

Yes

No
Please explain.
Have you ever attempted suicide?*

Yes

No
If yes, please describe dates, method and events that led up to the attempt.
Have you ever had thoughts of physically harming others?*

No

Yes, in the past

Yes, recently
If in the past, please explain.
If recently, do you have a plan? Please explain.
Comments

Appointment Request Form

Step 1 of 4

Client Insurance Information:

Mental Health History

Contact

join OUR mailing list

Twitter Feed