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Vine Counseling Center

Thank you for your interest in Vine Counseling Center. Complete the form below to send us an email, or simply give us a call. We're looking forward to working with you.

  • 773-914-2175

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    Forms

    Download Patient Forms Here

    Child/Adolescent Registration Form
    Click to Download (pdf)

    Adolescent Release of Information
    Click to Download (pdf)

    Child/Adolescent Intake Form
    Click to Download (pdf)

    Child Release of Information
    Click to Download (pdf)

    Adult Registration Form
    Click to Download (pdf)

    HIPPA Form
    Click to Download (pdf)

    Adult Intake Form
    Click to Download (pdf)

    Adult Release of Information
    Click to Download (pdf)

    VCC Teletherapy Consent Form
    Click to Download (pdf)

    Vine Authorization Payment Form
    Click to Download (pdf)

    Virtual Session Available

    Receive confidential mental health counseling services right in the comfort and safety of your own home with Vine Counseling Center. We provide teletherapy services via secure video chat.

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    Contact Information

    Schedule an initial no cost consultation with Vine Counseling Center to learn more about how we can support you. Call or send us a message today to get started.

    Vine Counseling Center

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      Please tell us what kind of services you are interested in (check all that apply):

      What location(s) are you interested in (check all that apply):

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