New Client Request Form

New Client Request Form

Please complete the form below. Our Intake Coordinator, Jamie Dunlap, will be in touch with you via email or phone in the next 24-48 business hours to schedule a brief follow-up call. This form shall not be interpreted as entering you into a therapeutic relationship with CCP or any therapist working for CCP.
Client Information
Your Legal Name*

FirstLast
Preferred Name (if different)
CCP, by law, must use your legal name on all insurance documents, but will endeavor to use your preferred name on all other documents.
Partner's Name (if interested in relationship counseling)
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Legal Gender*
Actual Gender (if different)
CCP, by law, must use your legal gender on all insurance documents, but will endeavor to use your actual gender on all other documents.
Your Pronouns
How do you plan to pay for therapy services?*
We only accept Blue Cross Blue Shield (BCBS) PPO. However, many of our clients are “out of network” (have insurance with a company other than BCBS), and they pay us in full at the time of service. CCP then provides them with a monthly “superbill" (basically a statement with diagnostic information) that they provide to their insurance company for out of network reimbursement (usually between 60-80%). You would need to check on your particular policy to confirm what your out of network benefits are. Many clients end up out of pocket no more than their in-network copay.
How did you hear about CCP?*
If you were referred to CCP by someone directly, please enter their name/s here:
Therapy Information
Which of our services are you interested in?*

Individual TherapyRelationship TherapyGroup Therapy
What is it that you are hoping to address in therapy?*
Is there a particular type of therapist you are hoping to work with?
Is there a specific CCP therapist you are interested in working with?
This is not a guarantee that you will be placed with your preferred therapist but we will always do our best to accommodate.
Have you been to therapy before?*

YesNo
Availability
What days and times are you available for weekly or bi-weekly therapy sessions? *
Please select all CCP office locations that you are interested in:*

Oak ParkLoopLakeviewTeletherapy*
*Please note that all CCP therapists are primarily holding virtual/teletherapy sessions, but a few of our therapists are doing limited in-person sessions with proper safety precautions. Being open to teletherapy may increase your likelihood of being connected to a therapist and beginning therapy sessions more quickly.
Risk (Optional)

The following questions may be a bit sensitive as they relate to risk. We are asking these in order to determine whether CCP will be the right practice for you and your needs. Please do whatever you need to protect yourself while answering, or feel free to skip this section if you would rather answer these questions by phone. Note that our Intake Coordinator will ask follow-up questions to your answers during your intake call.
Are you experiencing any suicidal ideation or have you in the past?

Yes, currently.Yes, in the past.No, I have never experienced suicidal ideation.
Have you ever attempted suicide?

YesNo
Have you ever been hospitalized for any mental wellbeing concern?

YesNo
Do you have any past or current experiences with financial, emotional, violence, physical abuse, or sexual abuse?

Yes, currently.Yes, in the past.No, I have never experienced financial, emotional, violence, physical abuse, or sexual abuse.
Do you have any past or ongoing struggles with substance misuse?

Yes, currently.Yes, in the past.No, I have never struggled with substance misuse.
Are you currently engaging in, or have you ever engaged in any self-harm behaviors?

Yes, currently.Yes, in the past.No, I have never engaged in self-harm behaviors.
Sign & Submit

Once you have submitted your form, we will respond to you within 48 business hours. For your protection, CCP's computers are password protected and encrypted, and all of the data in our forms is separately secured and encrypted across a protected, 256-bit SSL connection.
Potential Client (or Parent/Guardian) Signature *

Clear
If Completed/Signed by a Parent/Guardian, Please Type Your Name Here

First NameLast Name
Should be Empty:

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New Client Request Form

Client Information

Therapy Information

Availability

Risk (Optional)

Sign & Submit