Child's Legal Name *

First Name

Last Name

Parent/Guardian's Name

First Name

Last Name

Parent/Guardian's Phone

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I would like to schedule:

Psychotherapy: Talk Therapy

Medication Management

Yoga Therapy

Preferred appointment location

In Person: Beachwood

In Person: Rocky River

Telehealth

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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