Contact Us

For more information about any of our services, please call 847-390-3004 during office hours (Monday-Friday: 9 a.m. – 5 p.m.).
To request an appointment, please fill out the form below:

How Can We Help? *
Mental HealthSubstance Use DisorderDUI Classes (In-person only)Narcan Training (In-person only)

Type of Appointment *In PersonTelehealth (Mental Health and Substance Use Disorder only)Information Only

Full Name *

Date of Birth *

Phone *

Your email *

Street Address*

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Preferred Method of Contact *
PhoneEmailText

Preferred Language

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relationship *

Consent and Signature
I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting this form does not guarantee an appointment and that a staff member from FBHC will contact me to schedule.

Inputting my name below represents my signature.

Signature *