Client Access
Program Application

Client Access Program (CAP) Client Renewal Application

* = required field

"*" indicates required fields

Client Information

Name
MM slash DD slash YYYY
Gender

Responsible Party (if different than client)

Name
MM slash DD slash YYYY
Gender

Note: Since beginning therapy at CCCOC, do you have or have you obtained health insurance coverage? Please provide the information below. Having health insurance does not prevent approval for the CAP.

Note: All information provided as a part of this application to Cornerstone Counseling Center of Chicago is confidential.

Financial Information

Max. file size: 100 MB.
Please note that the ONE of the following is 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.
I am applying for up to 10 sessions. I understand my application must re-authorized according to the time period established when approved. I understand that my request for a reduced rate may be revoked due to non-compliance to regularly participate in sessions and goodness of fit. By submitting this application, I testify that I have disclosed the information truthfully and to the best of my ability.*
This field is for validation purposes and should be left unchanged.