Get Started

Request A Consultation Or Intake

Use this page to request a general consultation or to send a basic intake request. These forms collect general, non-clinical information only. To book a session directly, use the Book a Session button.

Book a Session

These forms are for general, non-clinical information only. Please do not include diagnoses, medications, detailed symptoms, Social Security number, insurance ID or member numbers, or other sensitive medical information. This website is not a secure medical records system and does not claim HIPAA compliance.

Intake Request

Share basic scheduling and contact details so our intake coordinator can reach out. Clinical intake paperwork is sent separately through the secure patient portal — not through this website.

Full name *

Phone *

Email *

Preferred contact method *

City *

State *

Service requested *

Preferred visit type *

Preferred days / times

Insurance company (name only)

Company name only — do not enter a member ID, policy number, or group number.

Are you physically located in Illinois for telehealth visits? *

Optional short general note

Optional. Please do not include diagnoses, medications, detailed symptoms, Social Security number, insurance ID or member numbers, or other sensitive medical information. Maximum 400 characters.

I understand this form is for general, non-clinical information only and should not be used for emergencies, urgent concerns, protected health information, clinical details, records, or patient portal messages. *

360 Talk Therapy is not an emergency service. In a crisis, call 911 or call/text 988.