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Toll Free (888) 560-8848

Call: 330.722.4166

Office (330) 862-8848

Toll Free (888) 560-8848

Call: 330.722.4166

Request An Appointment

PATIENT FORMS

The following Payment Authorization Form must be completed
prior to your first appointment with your Therapist

at Cornerstone Wellness Center

What You Need to Complete:

Please review and sign the Payment Authorization Form
These forms are provided electronically and you may digitally sign each form.
If you prefer, you will also be able to download a PDF version of the form that you can complete but you must be sure to either email completed forms or drop them off prior to your first appointment.

If you are the parent or legal guardian of a minor child (herein, “Minor Client”), which means your child is under 18 years old, you must give your written permission and consent for the Minor Client to use the SimplePractice Software and Services.

You understand and agree, by signing this form, that the Minor Client’s use of the SimplePractice Software and Services will be governed by the same terms of service that are applicable to your use of the SimplePractice Software and Services.

You agree that the practice listed above has your permission and consent to use the SimplePractice Software and Services to schedule appointments, communicate with you and/or the Minor Client, document and administer the Minor Client’s care and treatment, utilize telehealth services, and all other actions in any way related to being the Minor Client’s provider.

By signing below, you also attest to and certify that you are the Parent/Legal Guardian of the Minor Client, and that you have current and unrevoked legal authority to grant permission and consent to the above listed practice permitting the Minor Client to use the SimplePractice Software and Services.

YOU AGREE, THAT IF AND WHEN YOU NO LONGER HAVE SUCH AUTHORITY, YOU WILL IMMEDIATELY NOTIFY THE MINOR CLIENT PRACTICE IN WRITING.

BY SIGNING BELOW YOU HEREBY AGREE THAT YOU, AS PARENT/LEGAL GUARDIAN OF THE MINOR CLIENT LISTED ABOVE, HAVE READ, UNDERSTAND AND AGREE TO THE TERMS OF THIS CONSENT AND THAT PERMISSIONS YOU HAVE GRANTED IN THIS CONSENT ARE WITHOUT LIMITATION.

Upon submitting this form you will automatically be taken to the Client Financial Responsibility Form.

⚠️ Important

All forms must be completed and signed no later than 48 hours prior to your first appointment to avoid delays or rescheduling.

How to Submit Your Forms

Complete forms online through our secure patient portal.
If you need assistance or prefer to fill them out in person, please contact our office at
330-862-8848 or 888-560-8848 or email hello@cornerstonewc.com