Mozes and Helen Stern Counseling Center

Please fill out the following fields to schedule an Intake Appointment with an Upward Community therapist. Once we receive the request someone will get back to you as soon as possible.

Patient's First Name(Required)

Patient's Last Name(Required)

Patient's Date of Birth(Required)

Patient's Age

Patient's Gender(Required)

Male

Female

Patient's Phone Number(Required)

Patient's Phone Number

Patient's Email(Required)

Patient's Email

Is the patient over the age of 18?(Required)

Yes, patient is over the age 18

No, patient is under the age 18

Patient's School Attending(Required)

Parents Marital Status (Married, Divorced, Separated, Widowed)(Required)

Parent's Info - 1 (Point Of Contact)

Parent's First Name(Required)

Parent's Last Name(Required)

Parent's Phone Number(Required)

Parent's Email(Required)

Parent's Info - 2

Please fill NA for Not applicable

Parent's First Name(Required)

Parent's Last Name(Required)

Parent's Phone Number(Required)

Parent's Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Do you have insurance? If so what kind (ie BCBS PPO)(Required)

*We do not accept Medicaid.

Reason for Intake

To prepare for an Intake Appointment please fill out the appropriate form:

After filling out the appropriate form above, please download and fill out the Credit Card Authorization Form below and scan it back to us at intakes@upwardcommunitychicago.org.

Credit Card Authorization Form

Note: We currently only accept, BCBS PPO, United HeathCare, Aetna, Meritian, and Cigna.

Mozes and Helen Stern Counseling Center

Parent's Info - 1 (Point Of Contact)

Parent's Info - 2

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