Feelings Wheel

Download a pdf of the Feelings Wheel

CONTACT FORM- Name of Perspective Client or Person Wanting Info *

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Last

Please check what you are interested in: *

Homeworth Ohio Office In-person Counseling Intake
Contacting CAASS for other information (speaking engagements, medical records, any other non-intake questions)

Currently, ONLY the Homeworth Ohio (near Alliance, Ohio- 2.5 hours from Columbus) office is accepting new IN-PERSON clients. If you don't see the office you want to be listed above, it is currently not able to accept new clients. Check back periodically to see if we have openings in other offices. CAASS does not keep a waiting list. Inquiries to become a new client at other locations will not be responded to.

What services are you interested in? *

CAASS does not provide assessment for government/disability/social security services.

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

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

Email *

Phone number *

How will you pay for services/what health insurance company do you have? CAASS may be able to offer you a discounted self-pay rate. *

*CAASS not in network with this insurance provider, but may have clinical partner providers who are at the Homeworth location.

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

Age of Prospective Client

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

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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.

Name

Current Clients

If you need to contact your provider please contact them though the client portal (best way) or call or email them directly.

Office Locations

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