New Client Request Form

CCP New Client Request Form

Please complete the below form to schedule your initial 15-minute consultation. Please note that this consultation is a phone consultation (not video) that will take place with CCP's Intake Specialist. If you are requesting a specific CCP therapist, you will be connected with them after the call pending availability & goodness of fit. Once this form is submitted, CCP's Intake Specialist will be in touch with you within 48 hours to schedule your consultation.
IF YOU ARE FEELING SUICIDAL OR ARE HAVING ANY THOUGHTS OF HURTING YOURSELF, DO NOT SEND A MESSAGE ON THIS FORM. PLEASE IMMEDIATELY CALL 911, GET YOURSELF TO THE NEAREST EMERGENCY ROOM, OR CALL THE NATIONAL SUICIDE PREVENTION LIFELINE AT 1-800-273-8255.

Please note that 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:
Please name the therapist:*
Therapy Information
Which of our services are you interested in?*

Individual TherapyRelationship TherapyGroup TherapyPsychosocial Evaluations (for Emotional Support Animals, Gender Affirming Surgery, Infertility Treatment, and/or Immigration Evaluations & Support)
What is it that you are hoping to address in therapy?*
Is there a particular type of therapist you are hoping to work with?
Are you open to working with a CCP advanced clinical intern at a reduced fee?*
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 ParkChicago Northside (Ravenswood)Teletherapy (anywhere in Illinois)
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. Please 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?

Yes, more than 6 months ago.Yes, in the past 6 months.No
Have you ever been hospitalized for any mental wellbeing concern?

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

Yes, currently.Yes, in the past.No, I have never experienced financial abuse, emotional abuse, 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

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
BEGIN INTAKE CALL ANSWERS HERE
Name of CCP Intake Person
Notes on Risk Questions Above
Must Fill Out for Any Risk Question Answered Yes (Currently OR in the Past). Explain potential client present day concerns and history for any question answered yes in intake above.
If the client is experiencing CURRENT suicidal ideation, please fill out the below:
Frequency of SI Thoughts?
Do the thoughts occur once or twice a day? Several times a week? Something else?
Protective Factors?
What helps you to cope with these thoughts when they occur? What prevents you from following through on the thoughts?
Plan: Do you have a plan to kill yourself? Please describe. If no plan, ask: If you were going to kill yourself, how would you do it?
Note: If the patient has a very detailed plan, this is more concerning than if they haven’t thought it through in great detail. If the plan is feasible (e.g., if they are planning to use pills and have access to pills), this is a reason for greater concern. Even if they do not admit to having thoughts of killing themselves right now, if they have a detailed plan, you should encourage them to call 911 or the NATIONAL SUICIDE PREVENTION LIFELINE AT 1-800-273-8255
If you do not think the client is currently safe, stay on the line with them and call 911 or stay on the line while they call 911.

Safety: Do you think you need help to keep yourself safe right now? A “no” response does not indicate that the patient is safe, but a “yes” is a reason to act immediately to ensure safety. Stay on the line with the person, and call 911 or stay on the line while the person calls 911 or puts you on the phone with another present adult who can call 911.

Support: Is there another adult there now that I can speak to? If so, ask to speak to that person, and get them to either call 911 or the Hotline at 1-800-273-8255.

If you think the client is currently safe, but is too high acuity for CCP, you can let them know that CCP cannot offer the level of care that would be the most helpful for this level of acuity and provide appropriate referrals.

If you think the client is currently safe, and that they might be appropriate for CCP, move on to the next questions.
Are you currently seeing a psychiatrist/psychiatric RN?
Per CCP policy, for your safety and ours, we will not accept any new client who has had a history of untreated suicidality, and we will not accept a new client with any current SI unless they are also seeing a psychiatrist and are willing to sign an ROI to allow continuity of care.
Any Final Notes?
Should be Empty:

CCP New Client Request Form

Client Information

Therapy Information

Availability

Risk (Optional)

Sign & Submit

BEGIN INTAKE CALL ANSWERS HERE