Please fill out the form below and our office will contact you as soon as we can. * indicates a required fieldPatient Name*(Required) First Last Is Patient a minor (under 18)?*(Required) Yes No Parent's Name*(Required) First Last Your Email Address*(Required) Your Phone Number*(Required)Patient Gender*(Required) Male Female Prefer not to say Other Patient's Date of Birth*(Required) MM slash DD slash YYYY Insurance Carrier BCBSIL PPO AETNA PPO Self Pay/Out of Network Solway Psychology accepts Blue Cross Blue Shield of Illinois PPO, Blue Choice, Aetna PPO and private pay.Insurance ID # Insurance Group # Weekly Availability for Sessions*(Required) Example: 8:30 - 10:30 AM Monday-Friday, Thursday afternoons.Please provide a few times when you might be available for a 10 minute phone call with our intake coordinator. What brings you to therapy?What services are you interested in? (Please check all that apply)*(Required) Individual Therapy Child Play Therapy Medication Evaluation (Psychiatry) Parent Guidance