Client Interest Form

Client Services Interest Form
Holiday Hours Alert: Our Client Services office is closed during the week of Christmas. We will contact you promptly upon our return to the office on December 30th. If you are experiencing a crisis or emergency, please call 911 or contact the Cuyahoga Crisis Hotline at 216-623-6888.

Cornerstone of Hope is dedicated to providing support, education, and hope to the grieving. We understand the courage and strength it took to even click on the link to determine what programs can benefit you or your family. We thank you for inviting us to walk this unique grief journey with you and consider it an honor to serve you.

The first step in our enrollment process is to complete this form in its entirety (please complete a separate form for each individual client that is seeking services). Once received, our clinical services team will review your information and will contact you by phone within one week of form submission. During that call, we will review your payment preferences and assist with next steps in enrollment. Please know there may be a delay in starting services, depending upon your availability, our counselor's availability, and volume of new clients. May God provide you the necessary strength to continue this journey.

If you have any questions about our services or this form, please contact our offices at 216-524-4673 (Cleveland) or 614-824-4285 (Columbus).
I would like to receive services at:*

Columbus OfficeCleveland Office
Client Information
Client Name:*

First NameLast Name
Client Date of Birth:*

MonthDayYear
Date
Gender:*
Client is:*

AdultChild (under the age of 18)
Parent/Guardian Name:*

First NameLast Name
If completing for a minor under the age of 18, please state your relationship:*
NOTE: Only the legal guardian of a minor child may complete this form on their behalf.
Proof of custody document(s):

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Parent/Guardian Date of Birth:*

MonthDayYear
Date
Service Requested:

Adult Individual Grief CounselingChild/Teen Individual Grief CounselingCouples Grief CounselingSpiritual Direction *Unable to bill insurance for these services
Spouse Information
Name*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Age:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary phone number:*
Please enter a valid phone number.
Secondary phone number:
Please enter a valid phone number.
May we leave a voicemail?*

YesNo
Email:*
example@example.com
Are you (or child, if interested in child/teen grief counseling) currently receiving any mental health services from another provider?*

YesNo
If yes, please specify services you are receiving:*
Payment Preference:*

Insurance - I would like to utilize my insurance for grief counseling services. I understand that insurance coverage for services cannot be guaranteed. *Unable to bill insurance for Spiritual Direction ServicesFinancial Assistance - I do not have active insurance coverage and would like to learn more about the financial assistance application process.Self Pay - I would like to pay out of pocket.
Insurance Provider:*
Insurance Provider Phone:*
Please enter a valid phone number.
Primary Insured Name:*

First NameLast Name
Primary Insured Date of Birth:*

MonthDayYear
Date
Employer of Primary Insured:
Insurance Group #
Insurance ID #*
Secondary Insurance Provider:
Secondary Insurance Provider Phone:
Please enter a valid phone number.
Secondary Insurance Group #
Secondary Insurance ID #
Photo of front of insurance card:*

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Photo of back of insurance card:*

Cancelof
Photo of front of secondary insurance card:

Cancelof
Photo of back of secondary insurance card:

Cancelof
Photo of front of drivers license or state issued ID card:*

Cancelof
Loss Information
Name of loved one who died:*

First NameLast Name
Age:
Date of death:*

MonthDayYear
Date
What was your relationship to the deceased?*
Cause of death:*
Name of loved one who died:

First NameLast Name
Age:
Date of death:

MonthDayYear
Date
Relationship of deceased:
Cause of death:
I was referred to Cornerstone of Hope by:
Any additional comments:
With my signature, I attest that I am seeking services for myself or I am the parent or legal guardian of the minor child named above. I understand that I may not complete this form for anyone else. NOTE: Cornerstone of Hope is not able to reach out to individuals who are not completing this form on their own behalf or do not have legal guardianship of minor child for whom they are seeking services.*

Clear
Should be Empty:

Client Services Interest Form

Client Information

Spouse Information

Loss Information