Provider Request Form

Mental Health Wellness Provider
Request Form

Eligibility Requirements: Organizations interested in being included on this website must provide services that support the emotional, mental and social well-being needs of individuals in the Barrington Area community. Organizations included in the site should be non-profit and government entities that offer services to the general public in the Barrington Area and fit within one of the service categories on the website.

For-profit organizations may be considered if they offer services to the general public in the Barrington Area and fit within one of the service categories in the attached table and provide services on a sliding fee scale.

If you meet our requirements, you can fill out our New Provider Request Form below.

FOR MORE INFORMATION, CONTACT:

Jeanne Ang
Director of Community Health

Advocate Good Shepherd Hospital
Community Health Program

EMAIL

Fill out my online form.