Name *

First Name

Last Name

Phone

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Preferred Method of Contact

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Which services are you interested in?

Therapy

Group

Neuropsychological Testing

Speaking Event

Parent Workshop

Format (applies to therapy only)

If you are considering therapy, please tell us which format you prefer.

In Person

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Either

Out-of-Network Acknowledgement *

Please note that Mind Chicago is not an in-network provider with insurance plans. Following appointments, we provide Superbills that you can submit to your insurance if you choose. For more information, please refer to Insurance & Fees page.