MOTLRT Client Interest Form

Client Services Interest Form
Cornerstone of Hope's Mid-Ohio Traumatic Loss Response Team is dedicated to providing support, education, and hope to the grieving. We understand the courage and strength it took to even click on the link to determine what programs can benefit you or your family. We thank you for inviting us to walk this unique grief journey with you and consider it an honor to serve you.

The first step in our enrollment process is to complete this form in its entirety (please complete a separate form for each individual client that is seeking services). Once received, our clinical services team will review your information and will contact you by phone within one week of form submission. During that call, we will assist with next steps in enrollment. Please know there may be a delay in starting services, depending upon your availability, and volume of new clients. May God provide you the necessary strength to continue this journey.

If you have any questions about our services or this form, please contact our office at 614-824-4285.
I would like to receive services in:*

Delaware CountyMarion CountyCrawford CountyMorrow County
Client Information
Client Name:*

First NameLast Name
Client Date of Birth:*

MonthDayYear
Date
Gender:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary phone number:*
Please enter a valid phone number.
Secondary phone number:
Please enter a valid phone number.
May we leave a voicemail?*

YesNo
Email:*
example@example.com
Are you currently receiving any mental health services from another provider?*

YesNo
If yes, please specify services you are receiving:*
Loss Information
Name of loved one who died:*

First NameLast Name
Age:*
Date of death:*

MonthDayYear
Date
Relationship of deceased:*
Cause of death:*
Name of loved one who died:

First NameLast Name
Age:
Date of death:

MonthDayYear
Date
Relationship of deceased:
Cause of death:
Any additional comments:
Please verify that you are human*
Should be Empty:

Client Services Interest Form

Client Information

Loss Information