Contact us

Chosen name *

First Name

Last Name

Phone

(###)

###

####

Preferred appointment days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Any day / no preference

Preferred appointment times

Morning (8am - noon)

Afternoon (Noon - 4pm)

Evening (4pm - 7pm)

Anytime

Is your primary insurance through MetroHealth, Cleveland Clinic, University Hospitals, or Skyway Health Care? *

Larchmere Center for Well-Being is not an in-network provider for MetroHealth, Cleveland Clinic, University Hospitals or Skyway Health Care.

Yes

No

Is your insurance coverage through Medicare?

We don't accept Medicare

Yes

No

Legal name (this is for insurance purposes)

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of therapy you are seeking? Individual, Couples, or Family. *

Individual

Couples

Family

Are you interested in-person or virtual sessions?

Select your preferred choices

In-Person

Virtual

Both

No preference