Collaborative Care is located at 3723-25 N. Southport Avenue, Chicago, IL 60613.

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Collaborative Care Intake Forms

Below are links to forms that you can download and print. You can then e-mail the forms or bring them with you on your first visit.

If you have any trouble downloading and printing our forms, please contact our office at (773) 576-3925. You may either stop by to pick them up, or contact us by phone or e-mail if you would like them mailed to you. You may also fill them out at our office before your first visit.

For your convenience:

Clicking on either of the Intake Form links below will open a new window to load the form and/or launch the Adobe Acrobat Reader application.

Download & Print Intake Form

Download and print the PDF Intake Form here. Bring the completed form with you on your first visit. PC/Mac compatible, for all users.

Adobe Acrobat Writable Intake Form

Please note: The writable form can only be used with Mac OS and Adobe Acrobat Reader. If you are using the Preview application the form will not respond as intended.

Use the "Submit" button to send your completed form to Jackie via e-mail. Clicking the "Submit" button will open your default e-mail client with the form as an attachment. Send your e-mail and we will be in touch shortly to confirm its receipt.