If you are experiencing a medical emergency or are in danger, please call 911 right away.

By completing the contact form now, you’ll make the most of your time with our intake specialist, so we can jump right into understanding your needs and how we can support you.

We appreciate you taking a few minutes to complete it before your call!

First Name *

Last Name *

Phone

Email *

What time of day is convenient for an intake specialist to call you (Friday office closed at 3 p.m.)? *

Please share your referral source's name.

Are you enrolled in a Medicaid or a Medicare Plan? *

Would you like a courtesy insurance benefits check?

Insurance Provider

Member ID

Group ID

Name of Person Using Insurance

Date of Birth of Person Using Insurance

Insurance Company's Customer Service Phone Number

Please Upload the FRONT of Your Insurance Card

Upload a file

Please Upload the BACK of Your Insurance Card

Upload a file

Do you have a specific therapist you'd like to work with? *

Time and Location Preferences

Please note clients with flexible schedules are often able to be seen sooner, while evening and weekend appointments tend to book up well in advance.

Do you have a time of the day that you prefer? *

Do you have a preferred location for your appointments? *

Please Tell Us About Your Needs *

Consent Acknowledgements *

By checking this box, you agree to receive SMS text messages from Summit Family Therapy, LLC regarding scheduling, appointment reminders, and important updates. Message and data rates may apply. Message frequency may vary. Reply STOP to unsubscribe or HELP to (309) 271-1105 for assistance.

By checking this box I agree to receive occasional marketing messages from Summit Family Therapy, LLC. Message frequency varies. Message and data rates may apply. Text HELP to (309) 271-1105 for assistance. You can reply STOP to unsubscribe at any time.

By submitting this form, I consent to the processing of my sensitive personal information, including protected health information (PHI), which may be accessed by authorized members of this practice’s team.

By submitting this form, I understand that a quote of benefits does not guarantee payment.

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