MPA Schedule

Secure Scheduling Form

We are excited about the possibility of working together! Your completion of this convenient, secure multi-page form will give us the information we need to start the intake process. We will contact you within one business day (usually sooner!) of your form submission to discuss scheduling and, if applicable, give you a quote of benefits from your insurance company.

For general inquiries, please complete our general contact form. To request a benefits quote, complete our insurance card form. You may call us at (847) 864-0600 with any questions.

You may find it easiest to complete this form on your smart phone as photos of your insurance card are required on a subsequent page, if you plan to pay at least partially with insurance.

Your First Name *

Your Last Name *

How would you like us to communicate with you? *

Phone

Your Email Address *

Email Risk Acknowledgement & Use Consent *

I understand that the use of email is inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to A Mindful Psychology Associates therapists and/or office staff communicating with me by email

Your Phone Number * 🛈

Do you plan to pay for your sessions at least partially with insurance? *

Yes, I plan to pay at least partially with insurance

No, I plan to pay fully out of pocket

Did you already provide your insurance information using our insurance card form? *

Yes, I already provided my insurance information

No, I did not already provide my insurance information