Legal Name *

First Name

Last Name

Parent/Guardian's Name (for minors)

First Name

Last Name

Phone

(###)

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Preferred appointment location

In Person: Beachwood (Tuesdays only)

Telehealth (Mondays-Thursdays)

First Available

How would you like to pay for sessions?

Self-Pay

Insurance

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

(###)

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