Unify Counseling | Contact Us

Email

Drop us a line and we’ll get back to you within one business day.

info@UnifyCounseling.com

Phone

Give us a ring and we’d be happy to answer any questions you may have.

1 (847) 996-9994

Offices

We would love to see you. Please make an appointment as we are often with clients.

Unify Counseling - Evanston

701 Main Street, Suite 203

Evanston, IL 60202

Unify Counseling - Northfield

400 Central Ave, Suite 220

Northfiled, IL 60093

Progress

Client Information

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Insurance

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Preferences

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Finalize

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Please complete the following questionnaire to take the first step toward working with us. Fields marked with an asterisk (*) are required.

Welcome, and thank you for your interest in our services.

Client's name

Email*

Phone number*

What is your/client's date of birth?*

Client's city of residence

Client's state of residence

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Progress

Client Information

1 of 4

Insurance

2 of 4

Preferences

3 of 4

Finalize

4 of 4

Insurance Information

For insurance policyholders, please provide your information so we can verify your benefits.

If you will not be using insurance, you may skip this section.

Client's legal name (on insurance card)

Are you the client, or is someone else?

What is your/client's insurance provider?

What is your/client's insurance card member ID?

Please upload your insurance info card (Front side)

Please upload your insurance info card (Back side)

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Progress

Client Information

1 of 4

Insurance

2 of 4

Preferences

3 of 4

Finalize

4 of 4

Preferences

Please let us know about your personal preferences and what services you are interested in.

Any additional preferences? (optional)

Do you have a preferred therapist, provider or preferred demographics? (optional)

What is your preferred setting?

What is your preferred language? (optional)

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Progress

Client Information

1 of 4

Insurance

2 of 4

Preferences

3 of 4

Finalize

4 of 4

Final Steps

Once you submit this form, a member of our client intake team will contact you within one to three business days with information on the next steps to begin working with us.

Ideal Start Date

How did you hear about us?

Would you like to share your reasons for therapy and/or presenting issues? (optional)

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Next step

Thank you for reaching out to Unify Counseling! We have received your submission and will be in touch soon to arrange your appointment.

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