Contact Embodied Wellness Center | Chicago Mental Health and Wellness

Name: *

First

Last

Preferred Pronouns: *

E-mail: *

Phone Number: *

Date of Birth: *

Who are you seeking therapy for? *

How will you be paying for services? *

If you are using insurance, what is your member ID number, including all letters and numbers? (if you do not have your insurance information on hand, please e-mail stephanier@embodiedwellnesscenter.com with a photo of the front and back of your insurance card prior to your first appointment. Please not that this information must be provided BEFORE the first session.)

What service(s) are you interested in? *

Individual Therapy
Couples Therapy
Somatic Therapy

Availability for Appointments: *

Tell us why you're seeking support. *

Therapist you'd like to work with: *

How did you find out about us? *

If other, how did you hear about us?

State you will be living in during your time in therapy: *

**Please note that Stephanie is licensed to practice in IL, IN, FL, and SC and Amanda is licensed in Illinois. We cannot take you on as a new client if you will be living out of the state(s) we are licensed in for the duration of therapy. Even if you have an IL, IN, SC, or FL home as your official address but will be living in another state (at school, with family, for work, etc.) while receiving therapy, we still cannot take you on. As all licensed therapists are bound to the licensure laws of their state, we recommend that you use a therapist listing service like PsychologyToday.com to find a therapist practicing in the state you'll be residing in during your therapy.