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Request an Appointment
Request an Appointment with a Therapist
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Name
*
First
Last
Phone
*
Preferred Time
*
Between 8 AM and Noon
Between Noon and 4 PM
Between 4 PM and 8 PM
Please check any applicable boxes
*
Active Street Involvement
Justice-System Involvement
Recent Victim of Violence
Family/Friend was a Recent Victim of Violence
Exhibits Violent or Aggressive Behavior (includes online)
Family Challenges and School Disengagement
If your neighborhood has been identified as having high gun violence
Anything you would like us to know or that you would like to know more about
*
Is this appointment being made by
*
Self
Guardian
Guardian Name
*
First
Last
Preferred language for therapy
*
English
Spanish
No preference
Preferred to any
Disclaimer
Joliet Township is NOT an Emergency Department, please report any and all emergency situations to 9-1-1. Please note that this form is for joining a waitlist only. Completing this form does not guarantee immediate access, enrollment, or availability. You will be contacted if and when a spot becomes available.
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