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Phone (330) 629-2434

We Accept Most Insurances

Patient Forms

Intake Information Form

Please complete the form below and submit. Note that all fields are required! If a field is not applicable to you, please type N/A in the field.

All information will be transmitted securely and will be kept strictly confidential. You are under no obligation to submit this form. Please refer to our Privacy Policy for more information.



Patient Information
Sex: Male   Female
Do you feel you have a problem with alcohol?
Yes   Maybe   No
Do you feel you have a problem with drugs?
Yes   Maybe   No
Do you feel the impulse to harm yourself or others?
Yes   No
Have you been upset for more than 7 days?
Yes   No
Is transportation going to be an issue?
Yes   Maybe   No


Insurance Information: Primary


Insurance Information: Secondary
Note: This section is not required.