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Provider: Chris Dumke BS change
Service:Individual Counseling Session change
Date/time:Fri, May 31 at 4:00 PM (CDT) change

Thank you for your interest in counseling services at Advocate Psychotherapy Services.  Your choice for services at this agency is not taken for granted, and everything will be done to ensure that your treatment is as effective as possible.  It is a worthwhile process that you are entering into and it is our privilege to work with you and / or your family members.

IF YOU ARE SETTING UP AN APPOINTMENT ONLINE FOR THE VERY FIRST TIME, PLEASE CHECK YOUR EMAIL WITHIN 10 MINUTES AFTER BOOKING YOUR APPOINTMENT BECAUSE YOU NEED TO CONFIRM YOUR EMAIL ADDRESS IN ORDER TO ENSURE YOUR SESSION IS SET ASIDE FOR YOU.  

Without doing this final step in the process, your appointment will not be reserved for you and opened back up online by our scheduling system.  
Please look for the email entitled "Instructions to Finish Booking Your Appointment with Advocate Psychotherapy Services".  Click on the link in that email.

This step is only necessary for brand new clients or ones using a brand new email address, and is in place to make sure that email confirmations or reminders are going to an accurate email address.

Please do not submit any Protected Health Information (PHI)

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First name*
Last name*
Email*
Phone*
Street address*
This helps ensure that we have an up to date mailing address for you.
City, state, zip*
Date of Birth
If you are a new client, please provide your date of birth so that your profile can be set up properly
For New Clients Only: Initial Session Paperwork Options
All new clients will be sent an email to access our client portal to enter their information directly into their file. If you would like an alternative option, please indicate which one in the drop-down list.
Which insurance company do you have, if applicable?*
Clients either pay for counseling out of pocket as "self pay" for the cost of counseling or can use insurance or EAP to help offset the cost. Please indicate your choice of how services will be paid for:
Who will be attending the appointment?*
Please list the names of the people attending the appointment, if more than one.
How did you hear about APS?
This helps us market our services better.
Send a message to your counselor about your appointment(s), if needed.
Reasons for cancellations are appreciated as well as any feedback you want your therapist to know about your appointment.
* required field