Office 2101 Front St, Suites 106 & 215 Cuyahoga Falls, OH 44221 Phone 330-836-8090 Fax 330-794-5912 Please enable JavaScript in your browser to complete this form.Service Requesting *Therapy ServicesEducational ConcernADHD or Attention ConcernChoice 5Services - Therapy. Medication Management, Educational Assessments, ADHD or Attention AssessmentsClient Last Name *Client First Name *Client is a *AdultMinorParent/Guardian Last Name *Parent/Guardian First Name *Phone Number *Email *Payment Options *Choice 1InsuranceSelf PayIn-Network Providers *Choice 1AETNAAnthem/BCBSCareSource MarketplaceCIGNAMedical MutualMutual Health ServicesSummaUnited Behavioral HealthOtherClient is responsible to verify benefit eligibility. Preferred Office *Cuyahoga FallsBrecksvilleLet us know when scheduling if you prefer a virtual appointment.Reason for Contacting The Cole Center *Academic ConcernBehavioral Health ConcernDoctor ReferralSchool ReferralPreferred Day *SunMonTuesWedThursFriSatTime *MorningAfternoonEveningHow Did You Find Us?Web SearchFacebookPersonal ReferralProfessional ReferralEmailSubmit Like this:Like Loading...
