Individual Sessions Intake
Hey There! Im so glad you are taking the 1st step to reaching out for support and a community. Please read these instructions completely to understand the commitment to getting these services.

* Individual therapy will be conducted by interns (students that are currently getting their Masters in Social Work)
* Individual sessions will be once a week for 45 minutes for 4 months.
* All Sessions will be done via Telehealth
* It is MANDATORY to also participate in weekly support group
* It is MANDATORY to meet with case manager at least 1x a month or as needed
* Only 1 missed session is allowed during the 4 month period. More than 1 missed session will terminate services.
* Cost is $10 a week which need to be paid at the beginning of the month (some months have 4 weeks some have 5 - Cost will be accordingly)
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Name *
Date of Birth *
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Address *
Phone Number *
Email *
Is it Ok to send you messages through: (check all that apply) *
Required
Emergency Contact - Please provide 2 people (Names, Phone number and relation to you) *
Language preference *
Are you taking psychotropic medication? If so, which one? *
How many babies do you have? Tell us about their ages *
Reason for requesting services? *
In the past 30 days, have you had thoughts about killing yourself? *
Are you involved with DCFS? *
Have you been in therapy before? Tell me about your experience *
Do you have health Insurance? If so, which one? (this will not affect you receiving services with us) *
Do you agree to the service commitment? (as stated above) *
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