Request Consultation with Cicely Green, LCPC of Chicago Black Therapists LLC

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All questions are asked to determine if I have the skills and experience to help you, and if we are a good match in therapy together. Your responses will remain confidential.

chicagoblacktherapists.com/book-therapy

Email *

Do you understand this form is to schedule a free consultation to potentially begin psychotherapy with the Founder & CEO of Chicago Black Therapists, Cicely Green? *

Yes

I do not need/want to work specifically with Cicely

I would like to find a different therapist through the Chicago Black Therapist Directory (Please discontinue completing this form and visit chicagoblacktherapists.com/directory)

Required

What is your name? *

What state do you reside in? *

How do you racially identify? *

What is your gender identity? *

What are your pronouns? *

Sexual orientation? *

Are there any other identities you wish to share with me?

How old are you? *

What do you do for work? *

What goals do you have for your life? *

What are you seeking to heal in therapy? *

What solutions or strategies have you used in the past to fix the problem you're seeking to heal? *

I've seen Psychotherapist(s) before

Coaching Services

Digital Course or Online Resources

Support System (Friends, Family, etc.)

Medication

Getting a pet

Unhealthy coping or escapism

Movement / Exercise

Meditation / Spiritual

Other:

Required

Why do you specifically want to work with me? *

What's your ideal timeline to be in therapy? *

3 months

6 months

1 year

Long term (more than one year)

Lifetime

All therapy sessions will be virtual. *

I agree

I would like to see a therapist in-person

My rate is $200 per session. I accept credit card, cryptocurrency, and HSA/FSA cards. I do not accept insurance as payment. *

I understand

Required

Since I do not accept insurance, insurance companies consider me as an "out of network" provider. If you are an Illinois resident, your insurance may have out of network benefits to reimburse you for sessions with me. I can provide you with a superbill at the end of each month that you can submit to your insurance company. Before scheduling a consultation or booking a therapy session, I recommend calling the number on the back of your insurance card inquiring about your “out of network” therapy benefits and learning about how to submit an out-of-network reimbursement claim. You can also use your HSA (Health Savings Account) debit card to pay for psychotherapy sessions, and you will add this HSA card as your payment method within your client portal. Learn more about why I do accept insurance by visiting chicagoblacktherapists.com/faqs *

I have contacted my insurance, and they will reimburse

I have contacted my insurance, and they do not reimburse

I prefer to contact my insurance at a later date

I do not have insurance, or I do not plan to use out to network benefits

I am not an Illinois resident

Other:

Select which times you can commit to sessions with me on a weekly or bi-weekly basis. *

Mondays at 4pm CST

Mondays at 6pm CST

Tuesdays at 4pm CST

Tuesdays at 6pm CST

Wednesdays at 4pm CST

Required

A free 15 minute phone consultation will be scheduled to meet, further determine if we are a good match, and discuss next steps. I will email you my calendar link for you to book a time that works for you. Which of the below times can you typically be available for this phone call? *

Tuesdays at 3:15pm CST

Wednesdays at 5:15pm CST

Required

What is the best phone number to reach you? *

What questions do you have for me? *

A copy of your responses will be emailed to the address you provided.

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