Contact 1 — Merry Go Round

get in touch.

To schedule an initial appointment or for general inquiries please complete the form and one of our therapists will reach out within 48 business hours. For verification of benefits, please fill out the provider information portion of the form.

Health In Tandem

3338 N. Lincoln Ave.,

Chicago, IL 60657,

UNITED STATES

708-320-9679

INFO@HEALTHINTANDEM.COM

Name

First Name

Last Name

Pronouns

Phone

(###)

###

####

Preferred Contact Method

How did you hear about us?

Insurance Provider

Insurance Member ID

Please write N/A if inquiring about sliding scale or not inquiring about setting up a session.

Insurance Group Number

Please write N/A if inquiring about sliding scale or not inquiring about setting up a session.

Customer Service or Provider Phone Number

This phone number can often be found on the back of your insurance card. Including this number will expedite verification of benefits. Please write N/A if unsure, inquiring about self-pay, or are not inquiring about setting up a session.

Date of Birth

This is required for verification of insurance benefits.

YYYY

Zip Code

Use the zip code that is attached to your insurance benefits.

Preferred Appointment Time

Check all that apply.

Weekdays from 8am-11am

Weekdays from 11am-2pm

Weekdays from 2pm-5pm

Weekdays from 5pm-9pm

Weekends from 8am-11am

Weekends from 11am-2pm

Preferred Location

Message

get in touch.

contact

Date, time & location