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Request an Appointment

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Please complete the form below to submit a request for an appointment with a mental health/substance abuse professional. If you are a parent making a request for your child, please put your child's information in the 'Client' section and your name in the 'Contact Person section'.

If you require immediate assistance or you are experiencing an emergency:

  • Call 911
  • Go to your nearest hospital emergency room
  • Contact our agency crisis line at 1-708-681-4357 (HELP)

Disclaimer:
Please note: This form is for requesting appointments with mental health/substance abuse professionals only. You may call the Central Access department to speak to someone directly about an appointment at 1-708-410-0615; Monday through Thursday 8:30 a.m. - 6:00 p.m. and Friday 8:30 a.m. - 4:30 p.m.

* Required fields

Client Name

Last Name: *
Middle Initial:
First Name: *
Client Date of Birth: *
Email Address:
Street Address: *
Apartment, Unit:
City: *
State: *
Zip Code: *
Primary Phone: *
Alternate Phone:
Best time to reach you at your primary phone: *  
Primary Language: * Other:
Secondary Language: Other:

Contact Name/Guardian (complete only if you are registering for someone else other than yourself)

Name:
Relationship to Client:
Primary Phone:
Alternate Phone:
Can we leave a message: Yes  No
Best time to reach you at your primary phone:  

Appointment Details

Preferred Appointment Day: *
Preferred Appointment Time: *
Please indicate which is most important to you: *  

Please continue to fill out the following information to complete your appointment request online.

Disclaimer:
All information provided is secured on this website and will be kept confidential.

Read Resurrection Health Care's Notice of Privacy Practices.

Reason for Referral

Check those that apply: *

Adult Counseling
Attention Deficit Hyperactivity Disorder (ADHD)
Alcohol and or Other Drug Related Problems
Child Counseling
Depression
General Anxiety
DUI Services
Family Counseling
Mandated Anger Management Classes
Mandated Domestic Violence Classes
Marital Counseling
Medication
Mood Disorders
Older Adult Issues
Panic Attacks
Relationship Issues
Stress
Substance Abuse
Teen Counseling

Call 877-RES-INFO for Nurse Advice, Doctor Referrals or Class Registration Monday - Friday 8 am to 8 pm • Weekends 8 am to 4pm
 
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