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First name

Last name

Phone Number

Email

City of Residence in Ohio

Zip code

five digits

Date of Birth

Month

Day

Year

Your date of birth helps us verify your identity and send the correct intake paperwork to you securely through our HIPAA‑protected system.

Type of Therapy You Are Seeking

Therapist Cultural or Racial Preference

Preferred Therapist (Current Openings Only)

In general what would you like to accomplish in Therapy?

I understand that all sessions at CTH are provided through secure, HIPAA‑compliant telehealth. CTH does not offer in‑office appointments in Cincinnati, Columbus, or any other city.

Appointments

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