General Inquiry Contact Form

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. Please note we are not offering couples/relationship counseling at this time. If you have questions or concerns, please contact info@rutticounseling.com
Client Name*
Is the client a minor?*

YesNo
How old is your child?
Parent/Guardian Name (if applicable)

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Will you be using insurance for your treatment?*

YesNo
What insurance will you be using?*
Do you have a specific clinician request? (only clinicians that are accepting a waitlist will be displayed)
Do you live in the state of Ohio?*

YesNo
What type of therapy are you requesting?*

In-personTelehealthNo preferenceCombination
Additional comments*
Please verify that you are human*
Should be Empty:

New Client Inquiry