If this is a mental health emergency, please click here. To schedule an appointment please contact our scheduling specialist or fill out the form below. Scheduling Specialist Sandy Chalkwater Sandy@growwellcle.com (216) 223-8773 Client's Full Name: Client's Date of Birth (mm/dd/yy): Parent/Guardian Name (for 18 and under): Address: City: State: Zip Code: Email: Home Phone Number: Cell Phone Number: Gender: Personal Pronouns: Preferred Name: Please specify preferred appointment days: SundayMondayTuesdayWednesdayThursdayFridaySaturday Please specify preferred appointment times: Morning (8AM-Noon)Afternoon (Noon-4PM)Evening (4PM-8PM)Anytime Preferred Office Location: TeleHealthOhio City Office (3000 Bridge Ave. Suite 4 in Cleveland)Lakewood Office (1662 Mars Ave. in Lakewood)Sheffield Office (5338 Meadow Lane Court in Sheffield Village) Please specify what type of counseling you are seeking: Individual CounselingCouples/Marriage CounselingFamily Counseling Please select if you are willing to work with an emerging practitioner (an intern): YesNo Please select if you are comfortable with an emerging practitioner (an intern) observing your session: YesNo Have you ever been treated for any mental illness? Such as by a psychiatrist, general practitioner, or other counselor/therapist: YesNo Have you been recently hospitalized for a psychiatric issue?: YesNo Are you currently experiencing suicidal thoughts or have had any in the past 6 months?: YesNo Have you ever attempted suicide? If yes, how long ago was this? If yes, have you attempted more than once?: Are you currently experiencing thoughts or urges to harm yourself or others? Have you had thoughts or urges in the past 6 months?: YesNo Are you an Ohio resident/physically in the state of Ohio during appointments?: YesNo Preferred Therapist: Please choose a preferred therapist Allison Borstad Ally McCarley Anita Dacanay April Elsasser Brian Moser Carolyn Allen Cassie Kingan DeQuan Brown Douglas Davis (intern) Duncan Simpson Emily Pohorence Erik Ribera Erin Dean Group Only Holly Hengartner Jackie Fry Jacob Irey Jessica Sen Julie Lineburgh Kaeley Doyle Kate Allbritain Kim Hurlburt (intern) Kristy Mitchell Matt Plauny Michael Pennington Molly Martin Nick Chmura Nicole LaSelle Olivia Campbell Pete Finnerty Rachel Astorino (intern) Stacey Sinwald Theo Eiben Trisha Zivkovic (intern) Alternate Therapist: Please choose a preferred therapist Allison Borstad Ally McCarley Anita Dacanay April Elsasser Brian Moser Carolyn Allen Cassie Kingan DeQuan Brown Douglas Davis (intern) Duncan Simpson Emily Pohorence Erik Ribera Erin Dean Group Only Holly Hengartner Jackie Fry Jacob Irey Jessica Sen Julie Lineburgh Kaeley Doyle Kate Allbritain Kim Hurlburt (intern) Kristy Mitchell Matt Plauny Michael Pennington Molly Martin Nick Chmura Nicole LaSelle Olivia Campbell Pete Finnerty Rachel Astorino (intern) Stacey Sinwald Theo Eiben Trisha Zivkovic (intern) Primary Insurance: Please choose an insurance provider Aetna Anthem/BCBS Beacon Buckeye Caresource Cigna Humana Humana Military/Tricare Medicaid Medical Mutual Medicare Molina Mutual Health N/A - Self-pay OSCAR Paramount SummaCare UMR United Healthcare Behavioral Health