Contact — Cleveland Health and Wellness Center

Request An Appointment

Legal Name

First Name

Last Name

Preferred Name (how would you like us to refer to you?)

Your Pronouns (he/him, she/her, they/them)

Phone

(###)

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I would like to schedule:

Psychotherapy: Talk Therapy

Medication Management (up to age 50)

Yoga Therapy

Briefly explain your reason for seeking therapy

What are you looking for in a therapist?

Preferred appointment location

In Person: Beachwood

In Person: Rocky River

Telehealth

First Available

Date of Birth (month/day/year)

Legal Sex (for insurance purposes)

Home Address (Street/City/State/Zip)

When are you available for appointments? (e.g. weekday mornings)

How would you like to pay for sessions?

Self-Pay

Insurance

If you would like to use insurance, which insurance plan do you have? (e.g. Aetna)

Do you have any other insurance coverage? If so, what is it?

What is the Member ID number listed on your insurance card?

Are you the primary person listed on your card?

If you are not the primary insured, what is the full name, date of birth, phone number, and address of the primary insured?

What is the Provider Phone Number listed on your insurance card?

(###)

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How did you hear about us?

We accept the following insurance plans:

Aetna
Aetna OhioRise
Anthem
Blue Cross Blue Shield
CareSource
CareSource Marketplace
Cigna/Evernorth
Cleveland Clinic EHP Plus
Medical Mutual
Medicare *
Oscar
UMR
United

We are not able to accept the following insurance plans:

Ambetter
Buckeye
GEHA
Molina
Tricare

* Select therapists accept Medicare, and we also accept some Medicare Supplement plans. Please reach out to us or check directly with your insurance provider to confirm your coverage.