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Client Access Program Application

* = required field

    The goal of the Client Access Program is to ensure that cost is not prohibited when obtaining and maintaining therapy and mental health services. In order to confirm your rate and match you with a therapist who is the best fit, please complete the application as soon as possible. Upon application review, we will let you know what the approved rate is to assist you in paying your counseling fees and completing your recommended course of therapy.

    Responsible Party (if different than client)*
    1. Client Information
      1. EmailPhone
      2. SingleMarriedSeparatedDivorcedWidowedCohabitatingOther
      3. Note: All information provided as a part of this application to Cornerstone Counseling Center of Chicago is confidential.

        Clinical Information
        1. Individual-AdultInd.-Child/AdolescentCouplesFamilyPsych. Testing
        2. Therapist Assignment

            Cornerstone Counseling Center of Chicago is a psychotherapy training site for graduate students working towards their Masters or Doctoral Degrees in Psychology, Mental Health Counseling or Clinical Social Work. All of our sliding scale therapists are supervised by a Licensed Clinical Psychologist, Licensed Clinical Professional Counselor, or Licensed Marriage & Family Therapist. Cornerstone trains Post-Doctoral Fellows, Pre-Licensed Clinicians, Pre-Doctoral Interns, Advanced Therapy Externs, and Therapy Externs. The exact price range may vary based on assignment. We work with each client on a case by case basis in order to assure the best match between you and your therapist, the presenting issue, and to provide the most effective treatment approach. CCCOC will be mindful of the clients therapeutic preference but it is subject to alter based on clinical fit and availability.

          1. No PreferenceGraduate/Pre-LicensedFully LicensedDoctoral
          2. Financial Information
              1. Please note that the ONE of the following are REQUIRED with your application BEFORE the application can be processed*:
                a copy of your latest W2, 1099 or tax return form;
                a copy of the current payroll stub for each working member of the household;
                a copy of any regular income payments (unemployment benefits, disability benefits, investment payments, etc.);
                a copy of your latest bank statement. (Accepted formats: jpeg and pdf)

            1. YesNo If yes, what amount
            2. Briefly describe reasons you are seeking therapy and detail your need for financial assistance*

    Cornerstone Counseling Center of Chicago