Schedule an Appointment

Please complete the following form to schedule an appointment for a complimentary 10-minute initial phone consultation. Patient must be in the state of Illinois at the time of appointment.

Consultation will cover numerous areas related to your overall well-being. Dr. Shoaib Memon will answer any questions you have about working collaboratively.

Dr. Memon will contact you via phone at your scheduled appointment.

Name

First Name

Last Name

Phone

(###)

###

####

Appointment Date

Select date for a complimentary 10-min initial phone consultation

Appointment Time

Select time for a complimentary 10-min initial phone consultation

Insurance for Future Visits

Select an insurance for future therapy visits

What service(s) are you interested in?

Check all that apply

Couples Therapy

Family Therapy

Group Therapy

Individual Therapy

Medication Management

Unsure

Reason for Appointment

Provide a brief description of the reason for the appointment

How did you hear about us?

Chicago-Based Adult Psychiatrist & Psychotherapist

HELPING YOU ACHIEVE THE LIFE YOU WANT TO LIVE

Schedule an Appointment

Chicago-Based Adult Psychiatrist & Psychotherapist

77 W Washington St Suite 1910 Chicago, IL 60602