Information Intake - Clearview Mental Health
To help us provide the best possible care, please complete this form and a member of our team will reach out to help you schedule your first appointment with us.
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First Name *
Preferred Name *
Last Name *
Date of birth *
MM
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DD
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YYYY
Email *
Phone Number *
You consent to receive SMS customer care and marketing messages from Clearview Mental Health. Message frequency may vary. Standard message and data rates may apply. Reply STOP to opt out at any time. Reply HELP for assistance. Consent is not a condition of purchase. Your mobile information will not be sold or shared with third parties for promotional or marketing purposes. For details, see our Privacy Policy at https://www.clearview-mentalhealth.com/privacy-policy. *
Required
Sex (as it appears on your insurance) *
What type of care are you seeking? (please select all that apply)
Are you currently experiencing any of the following? (select all that apply)
Current care providers
Include the name of your Primary care provider, Therapist and any other relevant specialists.
All of our visits will be via telehealth, meaning your computer/tablet/phone. It requires your ability to have stable internet connection, a safe and private space, and your comfort using technology/a video service. (If you cannot answer yes to this question, we cannot schedule you and will send you resources to help find an in-person provider in your area.) 

I understand that I am being seen via telehealth/virtually meeting with my provider.
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Street address 1 *
Street address 2
City *
Zip code *
State of residence
Services are only available in Ohio at this time.
 *
Terms for scheduling
If you are seeking mental health services, due to high demand and limited availability, we will book your sessions based on information provided on this form. Once you have been booked, we will send you a confirmation email and text message (if you’ve opted to receive texts from us). After your first meeting with your clinician, you and your clinician will collaborate to decide if ongoing treatment is right for you, or if there are any considerations that would be better supported from another provider or treatment. 
Acknowledgment
Clearview Mental Health provides outpatient mental health services. In some cases, your needs may require a higher level of care.

Our Privacy Policy, Informed Consent, Statement of non-discrimination, and No Surprises Act documentation are available under "Clearview Mental Health" at the bottom left of our website.
 *
Recent treatment programs:
Have you recently been released from an in-patient care program?
Clear selection
Insurance Information
We recommend you contact your insurance provider to confirm your coverage details. Any fees we quote are only estimates until they are processed by your insurance company.
Insurance Provider
Insurance plan information at the top of your card:
Any other information written at the top of your card next to the insurance provider name.  For example:  Anthem BlueCross BlueShield: Gold PPO, or Cigna: Open Access Plus
Subscriber ID *
Group Number
Are you the primary subscriber of this insurance policy? *
Scheduling Information
Reminder: We will help you book your session based on the information you provided on this form. Once you have been booked, we will send you a confirmation email and text message (if you’ve opted to receive texts from us).
Preferred provider (optional)
If that provider is unavailable, we will help pair you with a provider of similar expertise. Please leave blank if you prefer the first available provider.
Do you require a provider of a specific gender? *
What is your availability on a weekly basis? (Please select all that apply) *
8am-10am
10am-12pm
12pm-2pm
2pm-4pm
4pm-6pm
Late night: 6pm-11pm
Not Available
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How did you find out about Clearview Mental Health? *
Thank you for you interest in scheduling with Clearview Mental Health.
Please hit the SUBMIT button to complete your form and one of our team members will reach out within the next 24 business hours to you schedule your first appointment.
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