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Home
Meet Us
Services
Resources
Client Portal
Contact

216-200-5433

support@liferebirthed.com

Contact Us

Contact us if you are interested in learning more about our services.

Note: Please do not complete the contact form if you are soliciting services, seeking employment or internship placement.

Contact careers@liferebirthed.com if you are interested working at Rebirth.

26300 Cedar Road 1105
Beachwood, OH 44122

216-200-5433
support@liferebirthed.com

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Initial Appointment Request - Step 1 of 14

Name *

First

Last

Email *

Phone *

Okay to text? *

Yes
No

Check Yes to opt-in and to receive communication via text message. Message and data rates may apply. We identify ourselves as "Rebirth" for confidentiality purposes.

Okay to leave a voicemail? *

Yes
No

We identify ourselves as "Rebirth" for confidentiality purposes.

Type of Service or Service(s) you are requesting *

Individual Counseling
Pre-Marital Counseling
Couples/Marriage Counseling
Therapy for Teen (13-18)
Group Counseling
Other

Briefly explain why you are seeking services. *

Which therapist(s) are you interested in working with?

Ayan (Immediate Availability)
Jessica (Immediate Availability)
Candice (Immediate Availability)
Precious (Limited Availability)
Shirley (Limited Availability)
Erin (Has waitlist)
Kimberly (Has waitlist)
Tierney (Has Waitlist)
India (Has waitlist)
Tilisha (Has Waitlist)

How are you paying for services? *

Do you have more than one health insurance plan? *

Yes
No

Please choose your second health insurance provider. *

Days and Times Requesting (EST)

Morning (8:00 -11:59 AM)
Afternoon (12:00 - 3:59 PM)
Evening (4:00- 9:35 PM)
Weekends (Saturday or Sundays)

How did you hear about us?

Google Search
Therapy for Black Girls
Psychology Today
Good Therapy
Other Professional
Word of Mouth
I am a current client
I was a previous client

Are you a resident in Ohio or plan to be physically located in Ohio to receive services? *

Yes
No

Terms of Use *

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision and Rebirth Counseling and Therapy Services harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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About us

Our practice specializes in treating individuals, couples, and families. Through years of experience, we’re confident that no problem is too great to overcome.

Office Hours

Office Hours are Available by Request

Contact Information

216-200-5433

888-740-9968

support@liferebirthed.com

Employment Opportunities

A Therapist Website by Brighter Vision