Log in

Remember Me

815-290-9711
This email address is being protected from spambots. You need JavaScript enabled to view it.

Home
About
FAQ
Forms
Seminars
Appointments
Make a Payment

Potential New Client

Thank you for inquiring about our services at Renew Counseling. We are glad you are here. We want to ensure we are the best fit for your needs. Please take a moment to complete the following form.

At this time Renew Counseling Services is specializing in INDIVIDUAL treatment for adult women.

Are you an adult (over age 21) woman?* Yes No

Your Name*

Your phone number*

Your Email*

Would you prefer an email or text follow up?* Email Text

Do you live in Illinois?* Yes No

What type of appointment are you seeking?* In Person Virtual

Please briefly describe why you are seeking counseling: (250 chars left)*

Are you specifically looking for Christian counseling?* Yes No

Do you have insurance that covers counseling?* Yes No

If yes, what is the insurance company's name?

Is your insurance through Medicare?* Yes No

Is your insurance a community health plan? (Medicaid)* Yes No

Are you available during the day on Wednesdays?* Yes No

Are you available during the day on Saturdays?* Yes No

Home
About
FAQ
Forms
Seminars
Appointments
Make a Payment