Request a Couples Therapy Appointment Your Legal Name * First Name Last Name Preferred Name Your Pronouns (he/him, she/her, they/them) Your Date of Birth (month/day/year) Email * Phone (###) ### #### Partner's Legal Name First Name Last Name Partner's Preferred Name Partner's Pronouns (he/him, she/her, they/them) Partner's Date of Birth (month/day/year) Partner's Email Partner's Phone (###) ### #### 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 Your Home Address (Street/City/State/Zip) When are you available for appointments? (e.g. weekday mornings) How did you hear about us? Thank you for contacting us. We look forward to supporting you at Cleveland Health and Wellness Center. We will respond within 1-2 business days. If this is an emergency, please call 911 or go to the emergency room. Couples therapy can strengthen your bond, increase empathy and understanding, and lead to secure attachment.
