Cognitive Behavior Therapy (CBT) Center New Patient Interest Form
Thank you for your interest in the CBT Center!

Please take a few minutes to fill out this quick form. It is important for us to make sure we understand what you need so that we can assess whether us and our services are a good fit for what you need right now. We practice only the most evidence-based treatments and want to make sure we have the expertise to help you.

We reach out to potential patients as soon as possible when we have an opening. Please keep in mind that there is a high demand for our services and our therapists often have waiting lists.

This form should only be completed by people 18 years and older. If you are younger than 18, please have a parent or legal guardian complete it for you.
Sign in to Google to save your progress. Learn more
Email *
How did you find out about us? *
If referred to us, please indicate who sent you our way.
Are you filling out this form for yourself or someone else? *
What is your first name? *
What is your last name? *
What is your date of birth?

Please note: We treat middle school-aged through older adult - ages ~12+ (we have some availability for grade school-aged kids)
What is the best way to contact you? 

Note: text messages and email make it easier for us to get back to you more quickly between meetings, etc.
What is your preferred phone number? *
What is your preferred email address? *
Why are you seeking treatment? (just a few bullet points) *
Have you been in treatment before? If yes, what did you find helpful or unhelpful about the prior treatment? *
Have you ever engaged in any serious self-harm or had suicidal thoughts? *
*If you currently are having suicidal thoughts in addition to having plans or the means to do so, please go to the nearest emergency room, call 988, or text “START” to the Crisis Text Line (741741). If you are outside of the country, please call the local emergency line immediately.*
Have you ever been hospitalized for mental health reasons? (Including residential treatment) *
We are considered an out-of-network provider which means that your insurance may or may not cover the cost of our services. However, we work hard to make our services accessible. If you have a Preferred Provider Organization (PPO) plan, they typically reimburse around 70-80% for out-of-network providers.
Please confirm that you understand the following:

You will be required to pay for your session in full at the time of service. We will provide you with a superbill at the end of each month that you can submit to your insurance company for reimbursement. We accept cash, check, or credit card; however, we require a credit card on file.

*To learn more about our current fees and insurance, visit the FAQs ( page on our website.*

Please confirm that you are willing to pay out of pocket for our services by initialing below indicating that you understand that the CBT Center is an out-of-network provider and you are willing to pay out of pocket for their services.
What state(s) will you be located in during therapy?
What is your schedule like? When might sessions be possible?

Spoiler alert: scheduling is one of the bigger barriers to getting an appointment. The more flexible you can be, the sooner we can get you in to see one of our CBT clinicians.
The CBT Center offers both sessions via our secure telehealth platform and limited in-person sessions at our new Highland Park headquarters (following CDC guidelines). Some of our CBT clinicians are exclusively telehealth and others offer both in-person and telehealth. Therefore, our waiting list for in-person sessions is longer. Please let us know if you have a strong preference either way. This will help us match you accordingly. *
Is there a specific CBT clinician you would like to work with? (note: we can't guarantee you will be paired with them or that they are available at this time)

You can read more about us at our website -
We are in the process of designing group treatment offerings. Groups are great evidence-based, cost effective ways to get access to treatment. They can be used a standalone treatment option or as an adjunct to your 1:1 work.

Would you be interested in joining a CBT skills or process group?
Do you have any special requests regarding your treatment? What else is important for us to know? *
Who is completing this form? Please provide your full name and any other information about (contact info, etc.) not captured above. And, thank you for taking the time to fill this out for someone you care about (even if that was yourself!)
Clear form
Never submit passwords through Google Forms.
This form was created inside of Report Abuse