You can use this form to request to start services (please complete the entire form), ask a question about our practice, message our front office, or send a document to the office. It will be transmitted securely.
If your preferred clinician has a full schedule and is temporarily unavailable, we will work with you to see if another clinician in our office might be a fit for you. If we can't accommodate you now and your need is not time sensitive, feel free to check back with us as availability can vary month to month. If you can't wait for us we suggest you "Find a Psychologist" at Ohio Psychological Association, ask a friend or your PCP for a recommendation, or browse area psychologists' websites for a compatible alternative.
We will get back to you via phone or email during front office business hours within a day or two. Email from us is secure as long as your email is private. If you are in crisis or need immediate assistance for your safety, do not wait for our reply -- call 911 or go to an emergency room.
If you prefer to speak with someone rather than fill out this form, call Joanna in our front office Monday – Thursday 8:30 AM - 3:15 PM at 419-537-0900, extension 100.
Note: If you are completing this form for someone other than yourself, make sure they know about it and give their details, not yours.
Please take photos of your insurance card(s) and upload below.
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