New Horizons Mental Health OH (Google)

1

Are You Concerned For Yourself Or A Loved One?* This field is required.Select one

Myself

A loved one

Both

2

What Is Your Main Concern?* This field is required.

3

Do You Have A Secondary Concern?

YESNO

4

What Is Your Secondary Concern?* This field is required.

5

How Long Has The Abnormal Mental Health Behavior Been Present?* This field is required.

Just recently

1-6 months

6-12 months

Over a year

6

Have You (or Your Loved One) Received Treatment For Mental Health Previously?* This field is required.Select one

Yes

No

I'm not sure

7

Are you on Medicaid/Medicare?* This field is required.Please select an option

Medicaid

Medicare

No

8

Please Select Your Insurance Provider* This field is required.

9

Which Therapy Are You Interested In?

Partial Hospitalization Program (PHP)

Intensive Outpatient Program (IOP)

Cognitive Behavioral Therapy (CBT)

I'm not sure yet

11

Can We Get Your Name?* This field is required.Enter your first and last name

First Name

Last Name

12

Where Can We Send More Information?* This field is required.Enter your best email address

13

What Is Your Phone Number?Enter Your Phone Number

Area Code

Phone Number

14

Terms and Conditions* This field is required.

15

Sender