Client 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 (Cleveland) or 614-824-4285 (Columbus).

I would like to receive services at:*

Columbus OfficeCleveland Office

Client Name:*

First NameLast Name

Client Date of Birth:*

Date

Gender:*

Client is:*

AdultChild (under the age of 18)

Parent/Guardian Name:*

First NameLast Name

Parent/Guardian Date of Birth:*

Date

Service Requested:

Adult Individual Grief CounselingChild/Teen Individual Grief CounselingCouples Grief CounselingFamily Grief Counseling

Support Group Readiness Assessment*

I am interested in scheduling a Support Group Readiness Assessment

*Cleveland location only. For Columbus clients seeking support groups, please register here: https://secure.lglforms.com/form_engine/s/oquw-DEQMlgpbYifPI_LNw

Name*

First NameLast Name

Date of birth:*

Date

Age:*

Our offices are open Monday through Thursday, 8:00AM to 8:00PM and Friday, 8:00AM to 4:00PM. What is your scheduling preference?

MorningAfternoonEvening

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.Financial Assistance - I do not have active insurance coverage and would like to learn more about the financial assistance application process.Support Group Readiness Assessment - I understand that I cannot use insurance for my Group Readiness Assessment and agree to the one-time cost of $75. Groups are free of charge after the completion of the one-time assessment. *Each individual who is interested in attending support groups must complete their own Group Readiness Assessment.

Insurance Provider:*

Insurance Provider Phone:*

Please enter a valid phone number.

Primary Insured Name:*

First NameLast Name

Primary Insured Date of Birth:*

Date

Employer of Primary Insured:

Group #

ID #*

Photo of front of insurance card:*

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Photo of back of insurance card:*

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

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Name of loved one who died:

First NameLast Name

Age:

Date of death:

Date

What was your relationship to the deceased?

Cause of death:

Name of loved one who died:

First NameLast Name

Age:

Date of death:

Date

Relationship of deceased:

Cause of death:

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.*

Clear

Please verify that you are human*

Client Services Interest Form

Client Information

Spouse Information

Loss Information