25000 Center Ridge Rd, Suite #5 Westlake, OH
440-892-7034
Toggle navigation
About
About
Our Providers
Frequently Asked Questions
Services
Counseling
Telehealth
Billing/Payment
Billing/Payment
Locations
Elyria
Ravenna
West Park
Westlake
Contact Us
Contact Us
About
About
Our Providers
Frequently Asked Questions
Services
Counseling
Telehealth
Billing/Payment
Billing/Payment
Locations
Elyria
Ravenna
West Park
Westlake
Contact Us
Contact Us
Contact Us
CJ Hendry
>
Contact Us
Please complete this confidential form to tell us more about you and your needs. You will be contacted by an Intake Specialist within one business day to schedule your first session.
Online Intake
What type of services are you interested in?
*
Services for Myself
Services for a Family Member
Marriage/Couples Counseling
Family Counseling
Employee Assistance through my Employer
Name
*
First
Last
*
Last
Birth Date
*
Primary Reasons for Seeking Services
Academic Challenges
Addiction
Anxiety
Depression
Eating Disorder / Body Image Issues
Grief or Loss
Life Transition Issues
Additional Information
Contact Information
Address
*
City
*
State
*
Zip Code
*
Phone
*
Email
*
How did you hear about us?
*
Online Search
Social Media
Family Member/ Friend
Doctor's Office
School
Church
From Another Client
Insurance Information
Insurance Company
Aetna
Aetna Better Health
Allied Benefits
Ambetter
Anthem BCBS
Beacon Health
Buckeye Community
Buckeye Health Plan
CareSource
Cenpatico
Church (Client)
Cigna
Cleveland Clinic
Continental Benefits
Employee Benefit Management Services
Healthsmart / UFCW
Horizon Advantage EPO
Impact
MagnaCare
Medicaid
Medicaid Mutual
Meritan
Molina
Mutual Health Services
Optum Health
Paramount
SummaCare
The Health Plan
TriCare
United Behavioral Health
United Healthcare
United Medical Services
Medicaid Yes/No
Medicaid
Non-Medicaid
Insurance Number
Group Number
Appointment Availability
Please list your general availability to schedule your first appointment.
Day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
AM/PM
AM
PM
After What Time?
Any
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
Day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
AM/PM
AM
PM
After What Time?
Any
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
Day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
AM/PM
AM
PM
After What Time?
Any
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
If you are human, leave this field blank.
Submit
Search