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Request a Visit

Please complete the form below and our office will contact you as soon as possible

First Name

Last Name

Preferred Name:

Pronouns

Date of Birth

Address

Phone

Email

Insurance

Insurance ID Number

Insurance Group Number (leave blank if it does not apply)

Subscriber's Full Name (if someone else than patient)

Subscriber Date of Birth (if someone else than the patient)

Subscriber's Address (if someone else than the patient)

Reason for your visit (describe briefly)

I confirm that the information given in this form is true

I give permission for Equal Mental Health to use the information provided to contact me, verify my insurance benefits, and create a record in their system.

Thanks for submitting!

Our office will contact you shortly

Safe and supportive space where the LGBTQ+ community finds
Equal Mental Health
3306 N Haslted St Suite 1 Chicago, IL 60657
312-825-1130
contact@equalmentalhealth.com

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