Make an Appointment

Avenues of Counseling and Mediation, LLC Online Intake Form

All asterisked fields are mandatory for submission, you will need your insurance card to complete this form. An Avenues Intake Coordinator will call you back within 24 hours.

Note: If you are a minor (under 18), a parent or guardian will have to complete this for you.


Client Information:

 
(MM/DD/YYYY)

Secondary Phone/Type

MaleFemale
 


Guardian Information:

(MM/DD/YYYY)

Primary Phone/Type

Secondary Phone/Type

MaleFemale


Insurance Information:

AetnaCleveland ClinicAnthemBehavioral Health SystemCignaCompsychEmeraldMagellanMedical MutualSummaTricareUnited Health CareValue OptionsOther
      
 

Subscriber Name

If the subscriber information is the same as the Client Information above, please check this box and proceed to "Concerns to be Addressed"
 
(MM/DD/YYYY)

Secondary Phone/Type

Concerns to be addressed

Academic TestingADD/ADHDAdolescent (13 to 17)Children (4-12)Anger ManagementAnxietyArt TherapyAssertivenessAsperger'sBehavioralBlended Family IssuesSubstance AbuseDepressionDivorceGrief/LossMediationMedication EvaluationParentingPersonality IssuesRelationship IssuesSelf-EsteemSelf-MutilationSexual OrientationStress ManagementTrauma/AbuseOther


Location and Available Schedule Times

If your schedule is flexible, you may be able to make a daytime appointment within a few days. Evening openings may take a bit longer.

MedinaBathBoth
 

Hours Available Are:
Morning: 8-12
Afternoon: 12-4
Evening: 4-8

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Tuesday

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Wednesday

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Thursday

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Friday

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Saturday

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