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Appointment Request
Please complete this form in its entirety. This is a secure, HIPAA compliant submission. You will be contacted via email (from Dr. Erin Cooper,
cooper@westsidebehavioralhealth.org
) or text (from 216-295-5624)
when there is an opening
. If you do not respond to our attempt to reach you within 72 hours, you may be removed from our appointment list. If you do not hear from us after a week
, please feel free to reach out again, but
PLEASE DO NOT TEXT OR EMAIL YOUR APPOINTMENT REQUEST and do not fill out the form multiple times. This is the best and fastest way to get an appointment. Voicemail, text, and email requests are returned LAST and repetitive entries create delays in responding.
**Please note that Dr. Cooper is out of the office until Monday, May 20th.
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* Indicates required question
Patient's legal first and last name:
*
Your answer
Patient's preferred name:
Your answer
Patient's Age:
*
Your answer
Patient's pronouns:
Your answer
Phone number of patient (Note: we may text you at this number):
*
Your answer
Email address of adult patient or minor's parent/guardian
(PLEASE DOUBLE-CHECK THIS HAS BEEN ENTERED CORRECTLY!):
*
Your answer
If you are completing this form for someone else, what is your name and relation to patient:
Your answer
If you are completing this form for someone else, what is your contact information:
Your answer
If you are completing this form for someone 18 years or older, are they aware that you are contacting us?:
Yes
No
Clear selection
I am looking for:
*
Individual psychotherapy for myself
Individual psychotherapy for a loved one
Individual psychotherapy for my child (*please note that we do not offer ABA therapy)
Family therapy (*please note that only Jeff Jack and Carol Hoffstetter provide family therapy. Jeff will see children and their parents; Carol will see minor or adult children and their parents. We do not have any adult family therapy providers at this time.)
Adult ADHD Assessment (*please ask about rates for assessments)
Child ADHD Assessment (*conducted by Jeff Jack; please ask about rates for assessments)
Evaluation for Autism (*conducted by Jeff Jack; please ask about rates for assessments)
Evaluation for other possible mental health-related diagnosis (*please ask about rates for assessments)
Letter for Gender Affirming Surgery or Hormones (*please ask about rates for assessments)
Professional Supervision / Consultation
Couples therapy waitlist (*please note that only Dr. Cooper offers couples therapy and couples therapy is not covered by insurance.)
Other:
Required
I would prefer to work with:
*
First available
Mackenzie Keriazes, PsyD -- ($175 per session; no after school/evening/weekend appointments only; virtual or in-person)
Jeff Jack, LPCC -- ($165 per session; limited virtual openings only, no after school/evenings/weekends)
Caroline Chaikin, LCSW -- ($150 per session; virtual, mid-day appointments only, no evenings/weekends)
Carol Hoffstetter, LISW-S -- TO BE ADDED TO WAITLIST ($165 per session)
Erin Cooper, PhD -- NOT ACCEPTING NEW PATIENTS AT THIS TIME; available for supervision/consultation only
Required
Please describe what brings you to therapy at this time or what kind of evaluation/assessment you are looking for:
*
Your answer
Do you have insurance that you're hoping to use? (**Please note: we do not verify insurance benefits coverage - you should contact your insurance provider to determine your cost)
*
Yes
No, self pay
If "yes" above, what is your insurance carrier? (PLEASE NOTE: We are only in-network with Medical Mutual and Aetna and are not Medicare or Medicaid providers. Jeff Jack is also in-network with Cigna. We DO NOT verify coverage.)
*
Medical Mutual
Aetna
Cigna (Jeff Jack is only in-network provider)
Out of Network; I will pay for sessions up front and a superbill will be provided to me for reimbursement.
I have LYRA and I also contacted you from their search engine
I have LYRA and I have not contacted you in any other way
I will pay for sessions and do not intend to involve an insurance company in my care
Please select your scheduling availability:
*
Flexible during the day
Mornings
Lunch hour
Late afternoon
Evenings
Weekends
Other:
Required
I am interested in the following types of appointments:
*
virtual
in-person
the option to switch between virtual and in-person as needed
whatever is available
How did you hear about us?
*
Your answer
Anything else you'd like us to know?
Your answer
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