Information Intake - Clearview Mental Health
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First Name *
Preferred Name *
Last Name *
Date of birth *
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/
DD
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YYYY
Email *
Consent to use SMS text messaging
Phone number *
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.
 *
Street address 1 *
Street address 2
City *
Zip code *
State of residence
Services are only available in Ohio and Michigan 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
We provide outpatient mental healthcare services at Clearview Mental Health and your needs may require a higher level of care than what we offer.

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
To confirm your share of the cost of care, we recommend you reach out to your insurance provider directly.   Any fees we may quote will only be estimates until they are processed through 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 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.
Preferred provider (optional)
If that provider is unavailable, we will pair you with a provider of similar skills. 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 to you within the next 24 business hours.
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