Therapy Request Form

If you are a NEW client wanting to get services and you have not been assigned to a therapist yet, please fill out our therapy request form and a member of our team will get back to you as soon as possible.

If you would rather call us then don’t hesitate to call us at 216-440-2936.

Therapy Request Form

Name
Address
Date of Birth
Which Office Do You Want to Be Seen At?
If only tele-health is available would you be open to utilizing tele-therapy?
Drop files here or
Max. file size: 256 MB.
    Drop files here or
    Max. file size: 256 MB.
      Address of Insurance Holder
      Date of Birth of Insurance Holder
      Do you have secondary/supplemental insurance?
      Enter Insurance Company, Group Number, ID Number
      Who is the policy holder for your secondary/supplemental insurance?
      Enter Insurance Company, Group Number, ID Number
      Enter Insurance Company, Group Number, ID Number
      If relative, please enter address of policy holder.
      Therapist Gender Preference
      How would you like to be contacted?