Total:
...
Are you seeking clinical consultation with a staff member from Gateway Family Services of Illinois? Please complete this form and a staff member will be in touch to schedule your consultation.
Clinician for consultation
Who would you like to schedule your consultation
Please select
Gabby Remole LCSW, NLC-C, EP
Michael Remole MA, LCPC, NCC, I/ECHMHC, NLC-C, EP
Please select
First and Last name of the individual seeking consultation
Email address
Phone number
Address
Which of the following best describes your role:
Who are you in relationship to the client?
Parent or Legal Guardian
Agency Social Worker or Foster Parent
School Official
Mental Health Provider currently providing services to client
Equine Professional
Other not listed
Briefly describe your reasoning for seeking consultation.
Provide information to ensure we maximize our time together.
Schedule your clinical consultation with a therapist from Gateway Family Services of Illinois. If you have a spouse, significant other or a clinical partner (Equine Professional & Mental Health Professional) you can join the consultation together. If you are seeking consultation for a team of 3 or more, please let us know to apply the group consultation rates. Please do not complete multiple forms for consultation on the same individual. Consultations will be scheduled as schedules allow.
Clinical Consultations must be booked at least one week in advance of the consultation start date. Full payment is required to finalize booking. In the case that you do not show to your scheduled time, you will be charged your full consultation fee. Consultations must be canceled more than 24 hours in advance if for a full refund. Consultations canceled less than 24 hours notice are eligible for a 50% refund.
Consultation options range from 60-90 minutes. Pricing varies from $175-$400 depending on the services you are seeking for consultation. This will be discussed with you during the initial phone call to schedule consultation.
Select your consultation option
Please select the option that best fits your consultation needs
Please select
120 minute Clinical Consultation with brain metric and recommendations
60 minute Clinical Consultation
90 minute Clinical Consultation
60 minute Equine Professional Consultation
90 minute Equine Professional Consultation
60 minute Non-Profit Organizational/Start-Up consultation
90 minute Non-profit Organizational/Start-Up consultation
Please select
How did you hear about the consultation services?
We want to say thank you to those who referred you to us. Let us know how you heard about Gateway Family Services of Illinois
Referred by a Social worker/counselor/other mental health professional
Social Media
Google Search Engine
Neurosequential Network
Natural Lifemanship
School professional
Terms of Service
I agree to the
terms of service
.
Signature
Clear
Verification
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20