Initial Appointment Request for Counseling Services, Beachwood, Ohio

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 *

Briefly explain why you are seeking services. *

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

How are you paying for services? *

Do you have more than one insurance, if so please select from below, if not select N/A *

Days Requesting

Morning
Evening
Weekends

How did you hear about us?

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.