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Testimonials
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We Are Hiring

CONTACT

To schedule a presentation by our staff, complete the Speaking Event form.

To make an appointment please call, email, or fill out the contact form below. We respond to all inquiries as quickly as possible. If you have not received a response to your contact form submission within 24 hours, please send us an email at intake@northshorefamilyservices.com.

Phone: 847-668-4295, ext. 700

Email: intake@northshorefamilyservices.com

Thank you for contacting North Shore Family Services! Please provide the following information to start the scheduling process. If you are unable to provide all this information now, please submit what you can and our intake department will contact you via email.
Client Information
Name*
First Last
Client's Legal Name (if different from above)
First Last
Client's Nickname/Preferred Name (if applicable)
Client's gender preference
Client's Date of Birth*
Month
Day
Year
Is the Client (this person may be different than who is completing the form) under 18?*
- Yes
- No
Parent's marital status*
- Single
- Married
- Divorced
- Separated
- Widowed
Parent/Guardian #1/Mom’s Name, Phone and Email*
Full Name Phone Email
Parent/Guardian #2/Dad’s Name, Phone and Email*
Full Name Phone Email
Child/Teen's Phone # (we recommend providing for appointment reminders)
Client's marital status*
- Single
- Married
- Divorced
- Separated
- Widowed
Email*
Enter Email Confirm Email
Phone*
Emergency Contact Person
Full Name Phone Relationship
Client’s Address*
Street Address Address Line 2 City State ZIP Code
Preference for in-person or HIPAA-compliant teletherapy sessions:
- In-person only
- Teletherapy (video) only
- In-person or Teletherapy
Please indicate your preferred office location(s). Check all that apply.
- Northbrook
- Skokie
- Park Ridge
- Libertyville
Primary Care Physician/Pediatrician*
Referral Information
So glad you found us! How did you hear about us?*
Please specify the referral name:*
Has the client or a family member seen a therapist at North Shore Family Services (NSFS) before?*
- No
- Yes
Full name of previous/current NSFS client/family member*
Name of NSFS therapist previously/currently seen*
How can we help you?
Briefly describe why you have contacted us:*
We typically schedule appointments weekly, but it may be more or less frequent, depending on your needs. Please list all available days and time frames the client is available for sessions.*
NSFS sends out appointment reminders. Would you prefer an email and/or text reminder?*
- Email
- Text
Insurance Information
Is the Client Insured?*
- Yes
- No
Client's Gender for insurance purposes:*
- Male
- Female
Who is your insurance provider?*
If "Other", please specify
We are considered an out-of-network provider for your insurance but many of our clients with out-of-network insurance are reimbursed up to 70% of our billed rates. At the time of a session, you would pay the session fee, and then we will file all claims on your behalf. Any reimbursement you are due will be sent directly to you.
Is your insurance an HMO?*
- No
- Yes
Please list your site number (found on the lower left side of your insurance card)*
North Shore Family Services is an in-network provider for the following HMO sites: 075, 145, 155, 184, 213, 246, 266, 318, 413, 435, 447, 468, 483, 492, 746, and 759
Insurance Member ID and Group #
Member ID Group #
Is the Client Primary insurance holder?
- Yes
- No
Primary policy holder's name
First Last
Primary policy holder's date of birth
Month
Day
Year
Primary policy holder address as noted on insurance
Street Address Address Line 2 City State ZIP Code
Primary policy holder's employer
Office visit copay amount, if known
Upload insurance card, if available (front and back)
Drop files here or
Max. file size: 32 MB, Max. files: 4.
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North Shore Family Services is a practice offering customized counseling services for

children
teens
parents
adults
couples
families

We are located in the North Suburbs of Chicago and have offered HIPAA-compliant teletherapy since 2019.

Locations:

900 Skokie Boulevard, Suite 218, Northbrook, IL 60062

8707 Skokie Boulevard, Suite 302, Skokie, IL 60077

1400 Renaissance Drive, Suite 405, Park Ridge, IL 60068

1580 S. Milwaukee Avenue, Suite 105, Libertyville, IL 60048

Call or email us today!

Phone: 847-668-4295, ext. 700

Email: intake@northshorefamilyservices.com

Fax: 847-668-4295

We are a practice offering counseling for children, teens, parents, adults, couples, and families. We have several convenient locations in the Chicagoland area.

Copyright © 2023, North Shore Family Services, PLLC. All Rights Reserved

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Our Locations

Libertyville – 1580 S. Milwaukee Ave., Suite 105
Northbrook – 900 Skokie Blvd., Suite 218
Park Ridge – 1400 Renaissance Dr., Suite 405
Skokie – 8707 Skokie Blvd., Suite 302

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