The SUMMIT Therapy Center

of Wooster, LLC

  (330)345-8450

New Client Intake

Our Forms

Click on the names of the forms below to download them


New clients should download, print, and fill these (*) forms out to the best of their ability prior to their first session.  If there are any questions about what to write in any part of a form, clients should just skip those areas and ask when they come in.


  • (*) New Client Data - This form contains all of the basic information about the client and insurance information.  This form may need to be completed over time or at various times during therapy if changes in the client's information occurs.
  • (*) Psychotherapist - Patient Services Agreement - This document outlines what the commitments and responsibilities are of both the psychotherapist and the patient to each other at SUMMIT Therapy Center.
  • (*) Patient Financial Policy - By signing this form, the client agrees to the financial obligations that they will have to SUMMIT Therapy Center as a result of therapy or other services that can be provided by SUMMIT Therapy Center.
  • Confidentiality Addendum for Minors and Parents - explains laws and policy regarding privacy rights of minors and parental rights to records access.  This should be read, understood, and signed by parents prior to their children's first visit.
  • New Client Referral - print this form and fill it out to the best of your ability and give it to SUMMIT Therapy Center on your first visit.
  • Request for Information - consent to release information, to whom the information is to be released, and to specify what information is to be released.