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Family Adult Child Therapy Services PLLC

Give Us a Call Today
(312) 835-7039

Client Intake Form

Please fill out the following form to help us understand your mental health needs so that we can match you with one of our mental health professionals.

First Name

Email Address

Last Name

Date of Birth

Will you be paying for services out of pocket or using insurance? *

Out of Pocket

With Insurance

If paying w/insurance, please provide your insurance provider's name

What brings you to therapy? What are the best days and times to reach you?

Phone Number

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Get the help you deserve

Give Us a Call Today
(312) 835-7039
contact@factspllc.com

Address

125 S Wacker Dr.

Suite 200

Chicago, IL 60606

6800 Weiskopf Avenue
Suite 150
McKinney, Texas 75070

8520 Allison Pointe Boulevard

Suite 220

Indianapolis, IN 46250

Contact

Email: contact@factspllc.com

Phone: (312) 835-7039

Fax: (469) 421-8594

Hours of Operation

Mon.- Fri. 9:00 am- 7:00 pm

Saturday- Sunday Closed

© 2025.factspllc.com

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