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If you are interested in becoming a client at Redefined Counseling and Consulting, complete the following document and a staff member will get back to you within 2 business days.

Client's First Name *

Client's Last Name *

Client's Birthday *

Name of person completing the form if different than client

Street Address *

Apartment, suite, etc

City *

State *

ZIP / Postal Code *

Phone Number *

Adult/Client Email Address *

Adolescent's Email Address (14+ years old)

General Information About Why You Are Seeking Counseling Services At This Time *0 / 1000

Referred By *SelfOther

Referred By Name

Preferred Provider *Please select one or more preferred providers.Alicia Blackley, LPCC-S [Not currently accepting clients]Tammy Cappadonna-Kloss, LPCC-S [Not currently accepting clients]Carolyn Chambers, MEd, LPCC, LICDC [Virtual only]Katy Flegal, LISW, LICDCKaitlyn Gerhardt, LPCC [Virtual only]Marissa Hadney, LPCLisa Kostansek, LPCC-SAngelina Nero, CTSavanna Pirosko, LPCLogan Ross, MA, CTRS, CTRyan Schaefer, LPC [Virtual only]Yael Schwartz, LPCCEmilene Shibley, PsyDAmilia Teren, LPCCDusty Timmons, LSC, CT

Type of Appointment *In-person counselingVirtual counselingOpen to either in-person or virtual

Available Days for Appointments *MondayTuesdayWednesdayThursdayFriday

Available Times for Appointments *8am – NoonNoon – 4pm4pm – 7pm

Insurance or Self-Pay *InsuranceSelf-Pay

Insurance Company Name *

Policy Holder's Name *

Policy Holder's Birthday *

Insurance Member ID# *

Insurance Group ID *

In order for Redefined Counseling and Consulting to verify your insurance benefits, images of the front and back of your insurance card must be uploaded to this document prior to submitting.

Front and Back of Insurance Card *Maximum file size of 15MB each

Drag and Drop (or) Choose Files

Redefined Counseling & Consulting

Phone: (440) 688-4308

Fax: (440) 206-5014

8251 Mayfield Road
STE #200
Chesterland, Ohio 44026