Welcome to Affiliates in Behavioral Health, LLC

6133 Rockside Road | Rockside Square Building II | Independence, OH 44131

Patient Registration Forms

216-520-5969

book an appointment

New Patient Information

Affiliates In Behavioral Health - New Patient

First Name *

Middle Initial *

Last Name *

Gender *

Female

Male

Insurance Company *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Home Phone *

Work Phone *

Alternative Phone *

If the patient is under 18, please enter the Parent or Legal Guardian contact information below:

First Name *

Middle Initial *

Last Name *

Is the contact information is the same as above? *

yes

Address *

Apt, suite, etc.

Country

City

State

Zip code

Home Phone 2 *

Work Phone 2 *

Alternative Phone 2 *

Please describe what issue(s) you would like to address with our clinical staff: (You may enter up to 300 characters.) *

Please follow up this submission with a phone all to Affiliates In Behavioral Health 216-520-5969 during office hours.