Client Access Program Application Client Access Program (CAP) Client Renewal Application * = required field "*" indicates required fields Client InformationName First Last Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Gender Male Female Responsible Party (if different than client)Name First Last Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Gender Male Female 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.Name of Health Insurance Company* Number of Dependents*DeductibleCo-Pay or Co-Insurance AmountNote: All information provided as a part of this application to Cornerstone Counseling Center of Chicago is confidential.Financial InformationNet Monthly Income (include all resources from jobs, child support, alimony, etc.)Total Yearly IncomeTotal Monthly ExpensesFileMax. 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.* Yes, I agree No, I disagree NameThis field is for validation purposes and should be left unchanged.