Make An Appointment

Please fill in the following information to begin the process of making your first appointment (Intake) with Portage Path.  Our Admissions department will contact you by phone to provide you with the appointment day and time.

While this form entry page does not reside on a secure server, any data submitted is encrypted and submitted to a secure server that uses industry standard SSL encryption to ensure your information is protected. Your personal information is always encrypted with industry standard 128-bit encryption from the time you click the submit button until the time it is safely on our internal system and removed from the internet.

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Male Female

(check all that apply)
Aetna
Anthem
Buckeye Community Health Plan
Caresource
Gateway Healthcare
Humana
Magellan Networks
Medical Mutual of Ohio
Medicare Part B
Medicaid (all plans)
Molina Healthcare
Paramount
Tricare
United Healthcare/United Behavioral Health
Wellcare
Self Pay (no insurance)

(check all that apply)
Depression
Anxiety
Mood Swings
PTSD
Psychosis
Eating Disorder
Anger
OCD
Marital/Relationship
Other

(check all that apply)
Legal
Housing
Financial
Aggression
Other issues observed: (Please list)



Yes No
Yes No
(check all that apply)
Inpatient
Outpatient
Substance
Past CSS client
Past Portage Path client
None

My doctor
Another therapist
A friend or family member
My insurance provider
Another company
Internet search
Phone book
Advertising/Promotion/Health Fair
Other

Please Note: Portage Path Behavioral Health is not able to accept all private insurance programs. Please call us at 330.253.3100 to find out more information.

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