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)

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

Address and Contact Information


Contact/Guardian Information

Complete only if you are registering for someone else other than yourself.

Yes  No

Appointment Details

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

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

Read Resurrection Health Care's Notice of Privacy Practices.

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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