client registration forms

After Completing the Client Registration Form, Please complete the Financial Responsibility form. After both the Client Registration Form and the Financial Responsibility Form are received, the Client Registration office will call to schedule your appointment. For your convenience, the health history forms are available with the links below. These forms are needed for your first session. Please print the forms, fill them out, and bring to your first appointment.


Please note: 

If you are scheduling for someone you have legal care of, Current Custody or Power of Attorney  documents are required before scheduling.  This helps us to appropriately determine consent for care and access to confidential information. Please submit the full document to the Client Registration office at 330-915-2364 or intake@emerge.org



Please click HERE to read EMERGE Counseling Service's NOTICE OF PRIVACY.


  • Client registration form

    Click here to fill out the Client Registration Form. A registration is required for each person requesting individual counseling.

  • FINANCIAL RESPONSIBILITY FORM

    Click here to fill out the Financial Responsibility Form -- Agreement for Payment. This must be submitted before an appointment can be scheduled.

  • Health History Forms

    Please click here to print the ADULT Health History Forms. Please fill the form out and bring to the first appointment.

    Please click here to print the MINOR CLIENT Health History Forms. Please fill the forms out and bring to the first appointment.

    Please Click here to print the RETURNING MINOR CLIENT Health History Forms. Please fill the forms out and bring to the first appointment.

  • Locations


    Click HERE to see our Satellite Offices and get directions to their locations.

  • Client Consent form

    The attached Client Consent Form will be filled out and signed in session with your clinician at your first appointment.. The form is available here for your review. You do not need to bring this form with you to your appointment.