Feelings Wheel

Download a pdf of the Feelings Wheel

Click Here to See the Founder's New Book Feelings Wheel 2.0

CONTACT FORM

Name of Perspective Client or Person Wanting Info *

First

Last

Age of prospective client *

Currently only accepting new clients age 17 and up

New Clients please check all current available times/locations combinations that you are able to get services at: *

SUN 1PM-6PM @ ONLINE VIDEO SESSION
WENS ALL DAY @ ONLINE VIDEO SESSION
ONLINE VIDEO SESSIONS At other times (for Ohio residents only)
Every-other MON 8AM-11AM @ COLUMBUS Ohio Office IN-PERSON
Every other MON @ HOMEWORTH/ALLIANCE Ohio Office IN-PERSON (Homeworth is 2.5 hours from Columbus)
Online Coaching Sessions- Various Days/Times Available (US residents only)
Need Other Info- Contacting CAASS for other information (e.g., client records, consultation, speaking requests)/anything other than becoming new client

How will you pay for services/what health insurance company do you have? CAASS offers a significantly discounted self-pay rate. *

*In-network services provided by clinical partner HMT LTD.

What services are you interested in? *

Email *

We normally only contact clients via email. If you need us to call or text you, make sure you let us know in the message section.

Phone number

What do you need/what challenges would you like help with? *

PLEASE don't send sensitive personal or clinical information via this form.

List City and State Proposed Client Lives In *

Name of Person Filling Out This Form (only if different from above)

First

Last

Anyone is welcome to use this form to make inquires about CAASS services for themselves or anyone else but be aware that if the perspective new client is a legal adult (age 18+) and not under the legal guardianship of person filling out form, this adult perspective client needs to contact CAASS directly to make an appointment and needs to sign all paperwork themselves. PARENTS OF LEGAL ADULTS CANNOT MAKE APPOINTMENTS FOR ADULT CHILDREN unless adult child has authorized CAASS to do so. If the perspective client is a minor (age 12-17) the parent or legal guardian should fill out form. Legal documentation is required to establish legal guardianship. If minor's parents are divorced, legal documentation needs to be provided to show parent making appointment has the right to make health care decisions for minor.

What is the main way you found out about CAASS?

Word of Mouth/Personal Referral
CAASS website
Web Search
Psychology Today
Another Mental/Medical Health Practioner
Read an article/YouTube Video
Other
Not Sure/Prefer Not to Answer

Name

18112

Office Locations

Online Coaching Services
Columbus, Ohio
Homeworth, Ohio
Can refer clients to partner practice in New Albany, Ohio.