Black On Black Therapy Intake Form

Black On Black Therapy Intake Form

Let's see if Black On Black Therapy would be a good fit! Please complete the information below.
We are glad you decided to take the first step in booking an appointment! Starting therapy for the first time (or again!) is rewarding but often can be a process. We have some key points to share to help you determine if you would like to move forward.

Fees and Insurance

You may self-pay at $160-$200 per individual counseling session and $250 per couples/partner session. You can use your HSA/FSA. Aetna PPO and Blue Cross Blue Shield PPO are accepted for Illinois. You can be provided with a superbill for possible reimbursement from your insurance plan if you are outside of Illinois or have an insurance plan that is not accepted. HMO plans and Medicaid/Medicare are not accepted.

Appointment Times

Sessions are lunchtime sessions scheduled Monday through Thursday from 10:00am to 1:00pm CST (11:00am to 2:00pm EST). Clients typically use their lunchtime or set aside dedicated time for sessions. Whichever option you decide, sessions will always be virtual, so you have the flexibility of not having to travel. However, ensure a private space in your home, office, or car to engage in counseling fully.

Scheduling Intake or Consultation

You may also indicate on the consultation questionnaire if you would like to move forward with scheduling your intake session. If you can be seen, you will be sent your intake paperwork to be completed within 24 hours via a secure client portal. You will then be prompted to self-schedule your first appointment in the client portal.

If you have additional questions, you can request a 15-minute consultation. You will be called at the next available opening.

You will receive an email if your consultation screening reveals that we may not be a good fit.
Legal Name

First NameLast Name
Preferred Name & Pronouns
Birthdate

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which service are you interested in receiving?

Individual TherapyGroup TherapyCouples/Partner TherapySupport GroupEthical Non-Monogamy Relationship CoachingHighly Sensitive Person CoachingImmigration Psychological EvaluationOther
How will you be covering the cost of your therapy sessions? ($160 to $200-per individual session; $250 per couples/partner session; $50 per group session)

Self-PayHSA/FSAAetna PPOBlue Cross Blue Shield PPOOther
Are you currently covered by a different health insurance plan that is not listed above?

No, I am only covered by an insurance plan listed above.No, I am not covered under an insurance plan at all.Yes, but I will be opting out of using my insurance.Yes, but I will be seeking out-of-network reimbursement from my insurance.Yes, I am covered under two different insurance plans.Other
What is your primary concern?
What is your secondary concern?
Please briefly describe your specific concerns leading you to therapy:
Have you been in therapy previously?

I have never been in therapyWithin 1-2 yearsWithin 3-5 yearsOther
Have you experienced a recent trauma?

YesNoUnsure
Do you struggle with substance abuse?

YesNo
Are you currently experiencing domestic violence or intimate partner violence?

YesNo
Are you currently experiencing suicidal thoughts?

YesNo
What are you hoping to achieve as a result of therapy? Please list your top 1-3 goals for therapy.
What type of therapy and style of therapist are you hoping to have?
If you're having a hard time answering this question, think about how you want therapy to look and feel.
You get the most out of therapy when you’re able to attend regularly. Are you able to commit to weekly or bi-weekly sessions at this time?

YesNoOther
When is your preferred session time? Please note that sessions are lunch time sessions. If your schedule is flexible, please check any times when you are normally available.

Monday (10am-1pmCST)Tuesday (10am-1pmCST)Wednesday (10am-1pmCST)Thursday (10am-1pmCST)
Where do you currently live?

FloridaIllinoisSouth CarolinaTexasOther
Telehealth services require a private space with the use of technology and a reliable internet connection. Please check all that apply for you.

I feel comfortable completing documentation electronicallyI have access to a reliable internet connectionI have access to a laptop or desktop computerI have access to a phone with internet serviceI have a private and confidential space to engage in therapy
Is there anything else I should know that would help support you in therapy?
How would you like to proceed?

I'm ready to get started! I would like to schedule an intake session.I have additional questions. I would like a 15-minute consultation.
If you are scheduling an intake session, please upload a picture of the front and back of your insurance card.

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How did you hear about Black On Black Therapy?

Chicago Black TherapistsInclusive TherapistsPsychology TodayMental Health MatchBlack Mental Health Directory ChicagoReferral by Friend/FamilyReferral by Healthcare ProviderGoogle SearchFacebookInstagramWebsite
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