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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 forms must be completed prior to your first appointment

with your Therapist at Cornerstone Wellness Center

At Cornerstone Wellness Center, your care begins before you walk through our doors.

To ensure we provide the most effective and compliant treatment experience,
all new patients must complete the following required forms prior to their first scheduled appointment.

These documents are essential for establishing care, protecting your privacy, and ensuring clear communication
between you, your therapist and Cornerstone Wellness Center staff.

What You Need to Complete:

Please review and sign each of the following forms.
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.

Patient Information Demographic Profile

Collects essential contact, insurance, and background details
to set up your records and provide personalized care.

Informed Consentfor Psychotherapy

Explains therapy goals, risks, and your rights;
granting permission to begin treatment.

HIPAA Privacy Policy NoticeHealth Insurance Portability and Accountability Act

Outlines how your personal health information is used, stored,
and protected under federal law.

Practice Policies

Covers clinic procedures, scheduling, cancellations,
and expectations to ensure a smooth care experience.

Consent for TeleHealth Services& Informed Consent to Treatment

Grants permission to receive therapy
through secure video or phone sessions.

Consent for Minor Usageof Software Services

Authorizes technology use in treatment,
such as secure messaging or telehealth.

Client Financial Responsibility Forms

Acknowledges your obligation to pay for services,
including insurance limitations or unpaid balances.

Payment Authorization Form

Allows the practice to securely charge
your card or payment method on file.

Release of Information

Gives permission to share your records with
specified providers, schools, or support systems.

⚠️ 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 [Insert Phone Number] or email [Insert Email].