Initial Appointment Request for Counseling Services, Beachwood, Ohio

Name *

Email *

Phone *

Okay to text? *

Yes
No

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
Couples Counseling
Therapy for Child or Adolescent (ages 8-17))
Other

Briefly explain why you are seeking services. *

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

Traci (Has immediate availability)
Jessica (Has limited Availability)
Tierney (Currently has waitlist)
Shirley (Currently has waitlist)
Erin (Currently has waitlist)
India (Currently has waitlist)
Esther (Not Accepting New Clients)
Angelia (Not Accepting New Clients)

How are you paying for services? *

How did you hear about us?

Days Requesting

Morning
Evening
Weekends

Please share anything else you would like for us to know

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.