Client Intake Form

Before You Arrive at SCRAM Systems of Illinois

Please fill out our Client Intake Form below before arriving at your first appointment. Information provided here will allow us to start your case prior to your arrival and will help your appointment go much quicker. The Information you provide will be kept secure and confidential. Please contact us if you have any questions.

Note: All individuals participating in a SCRAM program are required to provide a valid credit/debit card for all funds to be automatically withdrawn for services on a weekly, bi-weekly, or monthly basis.

Step 1 of 4

  • This will be your main contact number.