Initial Appointment Request for Counseling Services, Beachwood, Ohio

We are glad that you are taking the first step to begin your journey of wellness. We are providing only Online Counseling sessions. Please complete the form below to help us serve you. For additional questions, You can email support@liferebirthed.com.

Please enable JavaScript in your browser to complete this form.

Initial Appointment Request - Step 1 of 14

Name *

First

Last

Email *

Phone *

Okay to text? *

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? *

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?

Shirley (Limited Availability)
Jessica (Limited availability)
Precious (Limited availability beginning, unable to see Caresource Clients
Esther (waitlist)
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? *

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, 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.

Comment

Be sure to follow us on Facebook and Instagram.

24300 Chagrin Blvd. Suite 210
Beachwood, OH 44122

216-200-5433
support@liferebirthed.com