New Client Form

  • New Client Form

  • This form is to request a new client intake appointment.  If you are already a client of the agency please do not complete this form--call the office to schedule.  If you are in need of immediate mental health services please call our office 440-285-3568 during business hours or contact 988.  Please do NOT use this form if you require immediate services.  

  • Legal Gender*
  • Date of Birth*
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  • Format: (000) 000-0000.
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?

  • Insurance Information

  • Policy Holder Date of Birth
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  • Enrollment Questions

  • Are you a veteran?
  • Do you use tobacco?
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