For Someone Else

Your full name *
Your relationship to the person seeking care *

Please enter your own contact details below.

How would you like us to contact you? * Choose an optionPhone callEmail
May we leave a voicemail? * Choose an optionYesNo
Service of interest * Choose a serviceIndividual therapyCouples therapyFamily therapyTesting and assessmentsEMDR therapyParent consultation and coachingNot sure yet
Preferred office —Please choose an option—Buffalo GroveLincoln ParkTelehealthNo preference
What would you like help with? (optional)

A brief overview is enough. Please do not include detailed medical history, records, insurance ID numbers, or other sensitive information here.

Have they worked with a mental health professional before? (optional) —Please choose an option—YesNoPrefer not to say

Questions or preferences (optional)
I have permission or appropriate authority to contact PPH on this person’s behalf.
I agree that Progressive Psychological Healthcare may contact me about this request using the details I provided.

Submitting this form does not schedule an appointment or establish a provider–client relationship.

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