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.

We also require a credit card on file, so please download, complete, and return the Credit Card Authorization Agreement.

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 text photos of forms and insurance card (front and back) to Amy at 419-283-2732.

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 Agreement Form

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