New Client Inquiry
*Note: RCC is currently at capacity and on a waitlist* Please complete this form and we will contact you when a clinician has an opening and is available to see you. Completion of this form does not guarantee that you will be seen at the practice nor does it make you a client of the practice. If you have questions or concerns, please contact info@rutticounseling.com. Please note that RCC is not a crisis center. If you need immediate assistance or crisis care, please contact 988 or attend your nearest emergency room.
Client Name
*
Is the client a minor?
*
Yes
No
How old is your child?
Parent/Guardian Name (if applicable)
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Will you be using insurance for your treatment?
*
Yes
No
What insurance will you be using?
*
Do you have a specific clinician request? (only clinicians that are accepting a waitlist will be displayed and this is not a guarantee that this clinician has current availability)
Please Select
Laura Herrold Johnson
Rachel Williams
Mayra Crotty
Kaley Yutzy
Do you live in the state of Ohio?
*
Yes
No
What type of therapy are you requesting?
*
In-person
Telehealth
No preference
Combination
Additional comments
*
Please verify that you are human
*
SUBMIT
Should be Empty: