Contact Form & Appointment Request
Thank you for contacting Greenleaf! Fill out this quick contact and appointment request form and we'll get back to you in 1-2 business days. If you'd prefer to talk to someone right away, please call our offices at 330-376-9494, ext. 209 during our business hours, M-Th, 8 a.m.-7:30 p.m.
Today's date
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Month
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Day
Year
Date
Is this request for you or someone else?
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Your name (if filling this out for someone else)
First Name
Last Name
Legal name of person who will be receiving services
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First Name
Last Name
Preferred name or nickname (if different from legal name)
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (even if it's the same as yours)
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Please enter a valid phone number.
Email Address (even if it's the same as yours)
*
example@example.com
Do you prefer your appointments:
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In-person
Virtual
No preference
What time of day do you prefer for an appointment? (Choose all that apply)
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8-10 a.m.
10-12 p.m.
12-2 p.m.
2-4 p.m.
4-6 p.m.
6-8 p.m.
What is the best time for our intake specialists to contact you? (choose all that apply)
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Morning 8-12 p.m.
Afternoon 1-4 p.m.
Evening 5-7 p.m.
After you submit this form, one of our team members will call you to gather additional information to help find the right solution for you. These first steps in the process have to be done by phone. Once past this initial stage, if we were to offer email or text messaging as options to communicate, would you be interested? This is for appointments or administrative issues only; it wouldn't include personal client or counselor communications. Please choose all that apply.
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Yes, email
Yes, texting
Neither, I prefer speaking to someone by phone
No preference - I'm good with any of these
If Greenleaf offered text messaging with our scheduling and intake team, would you be interested ?
Yes
No
No preference
How did you hear about Greenleaf? (choose all that apply)
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Word of mouth
Referral from a friend or family member
Attended a Greenleaf event
Facebook ad
Facebook or Instagram feed
Internet search/website
Referral from another agency or organization
Court-mandated
Submit
Should be Empty: