CHHAMH University Therapist Intake Form

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At Coffee, Hip-Hop and Mental Health, we want to bridge the gap between communities and professionals. We are looking to collaborate with social workers, therapists, and other mental health professionals who can take on new clients that come to us through CHHAMH University.

We are currently only working with licensed therapists in the state of Illinois.

First and Last Name *

Email *

Phone number *

Are you licensed in the state of Illinois? We are currently working with those located in IL only. *

Yes

Type of licensure (e.g. LCSW, LPC, LCPC, etc.) *

Licensure number *

Years of experience *

Please list your top three areas of expertise *

How many clients are you able to take on right now? *

N/A

3 or more

What city / neighborhood is your practice based in? *

Are you doing in-person or tele-health appointments? *

In-person

Tele-health

Both

What is your availability? *

How can you be paid? (You can select more than one option) *

Sliding scale

Insurance

Required

If insurance, which providers do you take?

Part of our process is that we share your contact with prospective clients for them to reach out to you to schedule a consultation, which may then lead to formal sessions. Do you consent to us sharing your intake email / phone number? *

Yes

Is there any other information you'd like to share with us?

Please let us know any info you would like us to put on our website (your own website link, psychology today page, etc.) *

Submit

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