Pre-Counseling Questionnaire

Thank you for reaching out to Freedome Counseling LLC, PLLC regarding counseling services. Please answer the questions below to set up a free 15 min consultation. Please complete the entire form as we will NOT be able to confirm your consultation if the form is incomplete.

SMS Communication

Do you agree to receive text messages from Freedome Counseling sent from 312-416- 6174? Message frequency varies and may include appointment reminders and/or cancellations. Message and data rates may apply. Reply STOP or CANCEL at any time to end or unsubscribe. For assistance, reply HELP or contact support at 312-416-6174. See our Privacy Policy for details on how we handle your information. https://www.freedomecounseling.org/privacy-policies/3cf2ea41-3e39-4c12-831c-2d97fe627b5b

Yes, I agree to receive text messages from Freedome Counseling sent from 312-416-6174.

No, I do not want to receive text messages from Freedome Counseling.

Briefly describe why you are seeking counseling services.

Do you prefer Virtual or In-Person Services?

In-Person

Virtual

Hybrid (Both)

Please select your insurance type or how your services will be covered. Note: We are only in-network with the companies listed below.

If apart of an EAP Program, please provide your voucher code Or Authorization Number below:

Eager to start counseling right away? Please upload the following documents to get a head start on the intake process.

Please upload a picture of your Identification Card and/or Driver's License

Upload your file

Choose a file or drag and drop one here.

Please upload a picture of the FRONT of your Insurance Card (If you do not have insurance at this time please upload a picture of your ID here.)

Upload your file

Choose a file or drag and drop one here.

Please upload a picture of the BACK of your Insurance Card(If you do not have insurance at this time please upload a picture of your ID here.)

Upload your file

Choose a file or drag and drop one here.

How did you hear about us?

If you selected Personal / Organization Referral, please provide the name of the person or organization below.

Pre-Counseling Questionnaire

SMS Communication

Yes, I agree to receive text messages from Freedome Counseling sent from 312-416-6174.

No, I do not want to receive text messages from Freedome Counseling.

Briefly describe why you are seeking counseling services.

Do you prefer Virtual or In-Person Services?

In-Person

Virtual

Hybrid (Both)

Please select your insurance type or how your services will be covered. Note: We are only in-network with the companies listed below.

If apart of an EAP Program, please provide your voucher code Or Authorization Number below:

Eager to start counseling right away? Please upload the following documents to get a head start on the intake process.

Please upload a picture of your Identification Card and/or Driver's License

Upload your file

Choose a file or drag and drop one here.

Please upload a picture of the FRONT of your Insurance Card (If you do not have insurance at this time please upload a picture of your ID here.)

Upload your file

Choose a file or drag and drop one here.

Please upload a picture of the BACK of your Insurance Card(If you do not have insurance at this time please upload a picture of your ID here.)

Upload your file

Choose a file or drag and drop one here.

How did you hear about us?

If you selected Personal / Organization Referral, please provide the name of the person or organization below.