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1200 E. Wheeling Ave.
Phone 740-432-1800
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Reasons seeking services?
Have you been referred?
Referral source:
Your preferences (best x/days for sessions, type of provider, Therapy/CPST/Group)
Interested in EMDR?
Yes   No   Maybe  
Have you watched the EMDR video?    Click on Services, EMDR Therapy. 1 video is for children and 1 for adults.
Any Questions?
* Best way to contact you to set up services?
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