Client Intake and Service Assessment Request

If you require assistance submitting this form, please call our office at 815-308-0851. PLEASE BE ADVISED THAT THIS LINE IS UNSTAFFED, BUT MESSAGES ARE CHECKED REGULARLY MONDAY-FRIDAY. PLEASE LEAVE US A MESSAGE AND SOMEONE WILL RETURN YOUR CALL AS SOON AS POSSIBLE.

DISCLAIMER: If you are seeking services and/or support for yourself, please complete this form as you normally would. If you are a family member supporting a loved one with a mental health condition and are seeking services through NAMI MC- list yourself as the client. Your loved one needing services will need to fill out a separate Client Intake and Service Assessment Request. DO NOT COMPLETE THIS FORM FOR ANY INDIVIDUAL OTHER THAN YOURSELF AND PLEASE DO NOT SHARE PERSONAL INFORMATION THAT IS NOT YOUR OWN.