1200 E. Wheeling Ave.
Phone 740-432-1800
 Client Information
  First Name:  * Last Name:  *  
  Date of Birth:  * Birth Sex: 
  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  
Any Questions?
* Best way to contact you to set up services?
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