Request for C4 Services

In case of a medical emergency or if you are in immediate risk of harming yourself or others, please call 911 or seek the nearest emergency room immediately.

If you would like to speak to one of our crisis counselors or request a crisis assessment at your location, please call (773) 769-0205. Our mental health professionals are available 24 hours a day, 7 days a week to assist you or your loved one.

Is the service request for yourself?

Yes No

If not, please select who the service request is for

Name of the person needing services

Name of the person referring them, if applicable

Date of Birth

Email

Phone Number

Street Address

City

State

ZIP Code

Preferred Language

What service(s) are you requesting? Please select all that apply.

Initial Assessment Outpatient Therapy Psychiatry/Medication Management (Requires therapy or case management services) Telehealth/Virtual Services Case Management Other

Briefly describe the reason for your request. (Optional))

If referring to C4, are you the legal guardian?

Yes No

What is your relationship to them?

If they are a student, what school do they attend?

If they are a client/patient, please identify the agency you are with.

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