Client Interest Form

Client Services Interest Form
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.
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):

Cancelof
Parent/Guardian Date of Birth:*

MonthDayYear
Date
Service Requested:*

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

First NameLast Name
Date of birth:*

MonthDayYear
Date
Child(ren) Information
Child Name*

First NameLast Name
Child Date of Birth:*

MonthDayYear
Date
Gender: *
Child Name

First NameLast Name
Child Date of Birth:

MonthDayYear
Date
Gender:
Child Name

First NameLast Name
Child Date of Birth:

MonthDayYear
Date
Gender:
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.
Kindly provide both your primary and secondary insurance information (if applicable). In order to process your claims through insurance, we must be in-network with both insurance plans. Your insurance will refuse payment for services if all insurance providers are not disclosed. Our Client Services Coordinator will verify whether we are in-network, or you may contact your insurance provider(s) directly to confirm.

While Cornerstone of Hope makes every effort to provide you with an understanding of your financial obligations for services through an insurance benefit check, it remains your responsibility as the patient to be fully aware of the coverage and exclusions of your insurance plan. We strongly recommend that you contact your insurance provider directly using the number on your insurance card to inquire about your mental health and behavioral health benefits. This will help ensure you are informed of any potential costs that may be your responsibility during the course of treatment.

If you are already seeing a counselor at another agency, we are unable to bill insurance for your services at Cornerstone of Hope.
Primary Insurance Provider:*
Primary 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:
Please note - While we welcome inquiries from concerned friends, family members, and others, Cornerstone of Hope is not able to contact a grieving individual or family unless we hear directly from the individual or family. Because we know that people grieve in their own way and time, we recognize that unexpected calls may not be welcomed. We appreciate your faith and support of our mission and services. If you know of a family in need of grief support, please mention us and let them know we are here whenever they are ready.
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

Child(ren) Information

Loss Information