Advance Behavioral Health Services
If this is an emergency please call 911. Please enter the information on the form below and our intake department will contact you within 1 business day.
What is the reason for the appointment?
Patient's Full Name*
I am the patient*
YesNoOther
Gender at Birth*
MaleFemaleNot willing to Disclose
Gender Identity (Optional)
MaleFemaleNon-conformingMale-to-Female/Transgender FemaleFemale-to-Male/Transgender MaleOtherChoose not to disclose
Patient's Preferred Language:
Phone Number*
Area code
Phone
Date of Birth*
Address
Street Address
Street Address line-2
City
State / Province
Postal / Zip Code
Country
E-mail Address*
Insurance*
No InsuranceAetnaBCBS PPOCignaDupage/DULY Medical GroupIllinois Health PartnersHumanaKane County HMOMagellan HealthMedicareNorthwestern MedicineTricareOther Insurance
Insurance Cardholder Name
Insurance Card ID Number
Insurance Card Group Number
When is your preferred time for us to call you to schedule the appointment? (i.e. 8am-10am, 4pm-6pm etc)*
Have you previously attended our facility*
YesNo
Has the person seeking treatment ever been treated for mental health diagnosis in the past? If so, what was the diagnosis, who was/is the provider and when?
Is the patient currently taking any psychiatric prescription medications? If so, any injectible medications?
Has the patient recently been hospitalized in a psychiatric hospital? If yes, when?
Does the person seeking treatment have a pending court or legal case, custody evaluation, or wanting a one time evaluation? If yes, please explain.
Has the person seeking treatment received substance abuse treatment, Suboxone, or is currently abusing substances? If yes, please explain.
How did you hear about us?
Insurance Company ReferralReferred by another physician/therapistFriend/Relative ReferralOnline SearchOther
I have read and agree to the terms & conditions and I am at least 18 years old and have the authority to make this appointment.*
Please verify that you are human*