Behavioral Health Contact Form & Appointment Request

Behavioral Health Contact Form & Appointment Request

Thank you for contacting Greenleaf! Fill out this quick contact and appointment request form and we'll get back to you in 1-2 business days. If you'd prefer to talk to someone right away or have questions about the form, please call our offices at 330-376-9494, ext. 209 during our business hours, M-Th, 8 a.m.-7:30 p.m.
PLEASE NOTE: Due to the nature of an online form, our initial intake call will be to you, whether you are the client or the primary contact for someone else. We will not call a representee without having talked to their healthcare representative or guardian/parent/relative first.

All questions marked by an * are required by all.

Questions labeled (Required) are mandatory to those they pertain to. They must be answered to proceed.

Thank you!
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Contact name (Client or Parent, Guardian, Caregiver)

First NameLast Name
If this appointment for you? (Choose only one)
If you chose "No" to the above, what is your relationship to this person?
Required
What is the legal name of the person who will be receiving services? (Required)

First NameLast Name
Do you have permission to speak on behalf of this person and make appointments for them? Do you have paperwork that you will be able to supply prior to appointment via email or fax? (Required)
If you are making an appointment for one or more individuals, including yourself, please list their legal names below.
Do you have permission to speak on behalf of the above individuals and make appointments for them? Do you have paperwork that you will be able to supply prior to appointment via email or fax? (Required)
Do you or the person you are representing have a preferred name or nickname (if different from legal name)

First NameLast Name
Contact Information

Please fill this part out on behalf of yourself and the individual you represent who will be seen by a Greenleaf counselor, if it applies). If this form is for you, you will fill out all spaces, as you are the Primary Contact and Client.
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email Address
example@example.com
Primary Contact/Client Preferred Appointments:
What time of day is preferred? (Choose all that apply)
What is the best time for our intake specialists to contact you? (choose all that apply)
If Greenleaf offered text messaging with our scheduling and intake team, would you be interested ?
How did you hear about Greenleaf? (choose all that apply)
If you were referred to Greenleaf by another agency or organization, please let us know which one and who you are working with so we can connect back with them.
If you attended a Greenleaf event, which one and when?
Thank you for contacting Greenleaf!
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Behavioral Health Contact Form & Appointment Request

Contact Information