Mental Health Therapy Appointment

Mental Health Therapy Appointment
What type of mental health services are you looking for right now?

I'm looking for a one time check inI'm looking for ongoing servicesI'm not sure
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Student or Staff Member*

StudentStaff
Campus*

GBAGBNGBOGBS
Glenbrook ID Number*
Preferred Mode of Communication to Receive Outreach/Scheduling Information:*

TextChatEmailNo Preference
Appointment Inquiry*

First AppointmentFollow-Up - I have attended a therapy session at the GSHC before
Preferred Appointment Type*

In-PersonVirtualNo Preference to In-Person or Virtual Visit
Availability of Appointment (check all that apply)

Before SchoolAfter SchoolGold Block 1Gold Block 2Gold Block 3Gold Block 4Blue/Green Block 1Blue/Green Block 2Blue/Green Block 3Blue/Green Block 4
If you are comfortable, please share anything, including symptoms or problematic experiences, that will prepare for our session. This question is not required.
Insurance Information (we do not bill for these services, however, is helpful for accessing resources)

MedicaidPrivate InsuranceI am unsure
How did you hear about mental health services at Glenbrook School Health Center? (check all that apply)

Doctor/ProviderSchool StaffFriendOnline SearchMarketing Event
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