New Clients

Please download, complete, and return the New Client Form below by email to amychilders@amylistens.org at least 48 hours prior to your first visit, along with a copy of the front and back of your insurance card with the email. If you are not using insurance, please include the Self-Pay Agreement with your New Client Form.

If you are unable to email forms, you can mail them to:
Amy Childers Counseling LLC, 450 Cedar Lane, Waterville, OH 43566

Forms need to be received at least 48 hours before your first appointment is scheduled. You will receive a confirmation email upon receipt. Thank you!

Self Pay Clients

If you are not using your insurance for your visits, please download, sign, and return the self pay agreement form below by email to amychilders@amylistens.org at least 48 hours prior to your first visit.

Credit Card Authorization Agreement