CHHAMH University Therapist Intake

CHHAMH University Therapist Intake Form

At Coffee, Hip-Hop and Mental Health, we want to bridge the gap between communities and professionals. We are looking to collaborate with social workers, therapists, and other mental health professionals who can take on new clients that come to us through CHHAMH University. Thank you for reaching out to us. You are not automatically partnered with us by filling out this form. A team member will be in touch with you to schedule a full onboarding session. Please send your inquiries to ntu@chhamh.org

We are currently only working with licensed therapists in the state of Illinois.

Thank you for your patience and interest.

1. First and Last Name*

2. Email *

example@example.com

3. Phone number*

Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

4. Are you licensed in the state of Illinois? We are currently working with those located in IL only. Mark only one answer. *

YesNo

5. Type of licensure (e.g. LCSW, LPC, LCPC, etc.)*

6. Licensure number *

7. Years of experience*

8. Please list your top three areas of expertise*

9. How many clients are you able to take on right now? Mark only one answer.*

N/A123 or more

10. What city / neighborhood is your practice based in?*

11. Are you doing in-person or tele-health appointments? Mark only one. *

In-personTele-healthBoth

12. What is your availability?*

13. Part of our process is that we share your contact with prospective clients for them to reach out to you to schedule a consultation, which may then lead to formal sessions. Do you consent to us sharing your intake email / phone number? Mark only one choice. *

YesNo

14. Is there any other information you'd like to share with us?

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CHHAMH University Therapist Intake Form

CHHAMH University Therapist Intake

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