Please enable JavaScript in your browser to complete this form.OhioGuidestone Request for Services Form Who is filling out this form? *SelfParent/GuardianOther EntityClient InformationFormer ClientClient Last Name *Client First Name *Client's Preferred NameDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number *Social Security NumberGender *MaleFemaleTransgender - Presents as FemaleTransgender - Presents as MalePrefer Not to AnswerStreet Address *City *State *OhioOhioAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *Please enter your 9 digit zip code in the xxxxx-xxxx format. If you do not know your +4 zip code, enter your address on this page at the USPS website.County of ResidenceAdamsAdamsAllenAshlandAshtabulaAthensAuglaizeBelmontBrownButlerCarrollChampaignClarkClermontClintonColumbianaCoshoctonCrawfordCuyahogaDarkeDefianceDelawareErieFairfieldFayetteFranklinFultonGalliaGeaugaGreeneGuernseyHamiltonHancockHardinHarrisonHenryHighlandHockingHolmesHuronJacksonJeffersonKnoxLakeLawrenceLickingLoganLorainLucasMadisonMahoningMarionMedinaMeigsMercerMiamiMonroeMontgomeryMorganMorrowMuskingumNobleOttawaPauldingPerryPickawayPikePortagePreblePutnamRichlandRossSanduskySciotoSenecaShelbyStarkSummitTrumbullTuscarawasUnionVan WertVintonWarrenWashingtonWayneWilliamsWoodWyandotDo you give permission to receive text messages for scheduling purposes if you have shared your cell phone number below? *YesNoPhone (cell/home) *What type of phone is this? *CellHomeEmail *Email Marital Status *DivorcedLiving TogetherMarriedSeparatedSingle - Never MarriedUnmarried CoupleWidowedMarital StatusDivorcedLiving TogetherMarriedSeparatedSingle - Never MarriedUnmarried CoupleWidowedRace *Asian AmericanBlack/African AmericanMultiracialNative or Indigenous American and Alaska NativeNative Hawaiian or Pacific IslanderSouthwest Asian and Northern African (SWANA) or ArabWhiteRace Not ListedDecline to ProvideRaceAsian AmericanBlack/African AmericanMultiracialNative or Indigenous American and Alaska NativeNative Hawaiian or Pacific IslanderSouthwest Asian and Northern African (SWANA) or ArabWhiteRace Not ListedDecline to ProvideIf Other Race, Please SpecifyEthnicity *Hispanic or Latino/a/e originNot Hispanic or Latino/a/e originEthnicityHispanic or Latino/a/e originNot Hispanic or Latino/a/e originReligion *NoneCatholicChristianEasternJewishMuslimPentecostalProtestantOtherPrefer Not to AnswerReligionNoneCatholicChristianEasternJewishMuslimPentecostalProtestantOtherPrefer Not to AnswerIf Other Religion, Please SpecifyPrimary Language *EnglishAmerican Sign LanguageAmharicArabicBhutaneseBurmeseCambodianCongoleseJapaneseMaay-MaayNative North AmericanNepaliOromoOther Indo-EuropeanOther SlavicOther West GermanicPortuguese (and Creoles)ScandinavianSomaliSouth SlavicSpanishSwahiliTigrinyaVietnameseZomiOtherPrimary LanguageEnglishAmerican Sign LanguageAmharicArabicBhutaneseBurmeseCambodianCongoleseJapaneseMaay-MaayNative North AmericanNepaliOromoOther Indo-EuropeanOther SlavicOther West GermanicPortuguese (and Creoles)ScandinavianSomaliSouth SlavicSpanishSwahiliTigrinyaVietnameseZomiOtherIf Other Language, Please Specify Parent/Guardian Name (if client is a minor) *FirstLastParent/Guardian Name (if client is a minor)FirstLastRelationship *RelationshipEmergency Contact Name *Emergency Contact NameEmergency Contact Phone Number *Emergency Contact Phone NumberEmergency Contact EmailEmergency Contact Relationship *Emergency Contact RelationshipCounty Worker Name, if applicableFirstLastCounty Worker's Phone, if applicableFor clients involved with Children's ServicesReferral Date *How Did You Hear About Us? *SelectEmailFlyerTelevisionBillboardRadioSocial MediaWeb AdvertisementWeb SearchOtherIf Other, Please Explain *Referral SourceThis section is to be completed when another agency or entity is making the referralReferral Source *Select1DivineLine2HealthAccess Health StarkAchievement Centers for ChildrenADAMHS Board of Cuyahoga CountyADAMHS Board of Tuscarawas and Carroll CountiesAdams County Children ServicesAdult Parole/Probation UNSPECIFIEDAetnaAkron Children's HospitalAkron Metropolitan Housing AuthorityAkron Public SchoolsAllen County Children ServicesAlliance City SchoolsAmeriHealth Caritas MedicaidAnthem Blue Cross & Blue Shield MedicaidApplewood CentersArchbishop Lyke SchoolArea Agencies on Aging UNSPECIFIEDArrowhead Behavioral HealthAscension St Vincent Hospital Indianapolis Stress CenterAshland County Jobs & Family ServicesAshtabula County Children ServicesAsurgent HealthAthens County Job & Family ServicesAttorney UNSPECIFIEDAultman HospitalAvon Local SchoolsAvon Lake City School DistrictAyersville Local SchoolsBay Village City SchoolsBeech BrookBellefaire JCBBelmont County Jobs & Family ServicesBelmont Pines HospitalBerea City SchoolsBerea Municipal CourtBlack River Local SchoolsBlanchard Valley Health SystemBowling Green ClinicBowling Green Municipal CourtBowling Green State UniversityBrecksville-Broadview Hts School DistrictBright Beginnings - Educational Service Center of NEOBrightViewBrooklyn School DistrictBrookside Intermediate SchoolBryan Elementary SchoolBryan High SchoolBryan HospitalBryan Middle SchoolBuckeye Community HealthBuckeye Local School DistrictBuckeye MedicaidBuckeye RanchButler County Children ServicesCambridge Behavioral HospitalCanton City Health DepartmentCanton City School DistrictCare Alliance Health CenterCaresource MedicaidCarroll County Job & Family ServicesCarroll County Juvenile/Probate CourtCarroll County Municipal CourtCascade Career Prep High SchoolCatholic CharitiesCathy's HouseCaughman Health CenterCedar Ridge Behavioral Health SolutionsCenter for Families and ChildrenCherry Street MissionChild & Adolescent Behavioral HealthChild Development Council of Franklin CountyChild Guidance & Family SolutionsChild Protective Services UNSPECIFIEDChildren's Network of Stark CountyChildren's Physicians, Inc.Children's Resource CenterCincinnati Children's Hospital Medical CenterCity Mission of FindlayTruancy Court UNSPECIFIEDClark County Jobs & Family ServicesClearVista Health & WellnessClermont County Department of Job & Family ServicesCleveland Clinic - Main CampusCleveland Clinic - Akron General Medical CenterCleveland Clinic - Fairview HospitalCleveland Clinic - Hillcrest HospitalCleveland Clinic - Union HospitalCleveland Municipal School DistrictCleveland Rape Crisis CenterCleveland Regional Perinatal NetworkClintonville Community Resource CenterCloverleaf Local SchoolsCocoonColeman Behavioral Health - Summit CountyColumbus Behavioral Health LLCColumbiana County Jobs & Family ServicesColumbus City SchoolsCommQuestCommunity Action Against AddictionCommunity Corrections Center of NW OhioCommunity Corrections Program of Common Pleas CourtCommunity Hospital and Wellness CentersCommunity Memorial HospitalCommunity Mental Health UNSPECIFIEDCommunity Refugee and Immigration ServicesComprehensive Behavioral Health ServicesCornerstone Pregnancy ServicesCorrectional Treatment FacilityCounselor UNSPECIFIEDCourt/CJ-Felony UNSPECIFIEDCourts/CJ-Juvenile UNSPECIFIEDCourts/CJ-Municipal UNSPECIFIEDCourts/Other UNSPECIFIEDCrawford County Jobs & Family ServicesCrossroads HealthCuyahoga County Board of Developmental DisabilitiesCuyahoga County Board of HealthCuyahoga County Job & Family ServicesCuyahoga County Juvenile CourtDarke County Jobs & Family ServicesDaycare UNSPECIFIEDDayton Children's HospitalDe Luca, Kenneth A.,Ph.D and AssociatesDefiance City SchoolsDefiance/Paulding County Job & Family ServicesDefiance High SchoolDefiance Middle SchoolDefiance Municipal CourtDirections for Youth and FamiliesDoctor UNSPECIFIEDDomestic Violence Center UNSPECIFIEDDorr ElementaryDover Health Center of Aultman Orrville HospitalEarly Education CenterEast Cleveland City SchoolsEdison Elementary SchoolEl Centro De Servicios Sociales, Inc.Elyria Municipal CourtEmployer/EAP UNSPECIFIEDErie County Board of Developmental DisabilitiesErie County Children ServicesErie County Health DepartmentErie County Juvenile CourtEuclid City SchoolsFairfield Community Health CenterFairfield County Family, Adult and Children FirstFairfield County Job and Family ServicesFairfield Medical CenterFaith HouseFalcon Health CenterFamily & Child First CouncilFamily & Community Service IncFamily Drug Court UNSPECIFIEDFamily Resource Center of Northwest OhioFatherhood InitiativeFindlay Municipal CourtFindlay Recovery CenterFindlay Treatment ServicesFirelands Regional Medical CenterFirst Step RecoveryFour County Career CenterFranklin County Board of Developmental DisabilitiesFranklin County Children ServicesFranklin County Court of Common Pleas Adult ProbationFranklin County Juvenile CourtFranklin County Municipal CourtFranklin County Municipal Court Specialty DocketsFriend UNSPECIFIEDFriendly Inn SettlementFrontline ServicesFulton County Health CenterFulton County Job & Family ServicesGallia County Children ServicesGaraway Local SchoolsGarfield ElementaryGarfield Heights City SchoolsGateway Health & Wellness CenterGeauga County CourtsGeauga County Jobs & Family ServicesGenerations Behavioral HealthGreene County Jobs & Family ServicesGuernsey County Children ServicesHamilton County Jobs & Family ServicesHancock County Adult ProbationHancock County Children ServicesHancock County Juvenile CourtHarbor Behavioral HealthHarbor House Domestic Violence ShelterHardin County Job & Family ServicesHarrison County Job and Family ServicesHeadstart UNSPECIFIEDHealthridge Medical CenterHelp Me GrowHelping Hands PreschoolHenry County HospitalHenry County Job & Family ServicesHighland County Job & Family ServicesHighland School DistrictHighland SpringsHocking County Children ServicesHolland Intermediate SchoolHolloway Elementary SchoolHope Recovery CommunityHorizon Educational CentersHorizon Science AcademyHospital UNSPECIFIEDHumana MedicaidHuron County Job & Family ServicesIndependence Education Center NWO (IEC)Indian Valley Local School DistrictInstitute of Family & Community ImpactInsurance Company UNSPECIFIEDJail UNSPECIFIEDJefferson County Job & Family ServicesJefferson School DistrictKeeping Kids SafeKeyser Elementary SchoolKnox County Job & Family ServicesKobacker CenterLake County Department of Jobs & Family ServicesLakewood City SchoolsLamplight Counseling - MedinaLancaster City SchoolsLaura's HomeLawyer UNSPECIFIEDLegal Aid Society UNSPECIFIEDLicking County Job & Family ServicesLife Spring RecoveryLogan County Job & Family ServicesLorain City SchoolsLorain County Health and DentistryLorain County Jobs & Family ServicesLorain County Juvenile CourtLorain County Public HealthLorain Youth CrisisLouisville City School DistrictLucas County Juvenile CourtLucas County Adult ProbationLucas County Children ServicesLucas County SALLucas County TASCLutheran HospitalMadison County Job & Family ServicesMahoning County Job & Family ServicesMarion County Board of Developmental DisabilitiesMarion County Job & Family ServicesMarion County Juvenile CourtMarion General HospitalMarion Public HealthMary Haines PhDMaryhavenMarymount HospitalMassillon City SchoolsMassillon Dialysis CenterMay Dugan CenterMedina City SchoolsMedina County Health DepartmentMedina County Jobs & Family ServicesMedina County Probate & Juvenile CourtMedina HospitalMedina Metropolitan HousingMental Health of AmericaMental Heath Addiction & Recovery Services Board of Lorain CountyMentor School SystemMercer County Job & Family ServicesMetro Catholic SchoolMetroHealth Medical CenterMiami County Children ServicesMidwest Detox CenterMolina MedicaidMom's FirstMoms2B Ohio State Obstetrics GynecologyMonroe County Job & Family ServicesMontgomery County Job & Family ServicesMorgan County Job & Family ServicesMorrow County Job & Family ServicesMount Carmel Behavioral HealthMurtis TaylorMuskingum County Job & Family ServicesNAMINational Youth Advocate Program (NYAP)Nationwide Children's HospitalNeighborhood AllianceNeighborhood Family PracticeNeighborhood Leadership InstituteNew Care Behavioral HealthNew ConceptsNew Philadelphia Girl's Group HomeNew Philadelphia City SchoolsNew Philadelphia Municipal CourtNew Visions UnlimitedNewcomerstown Exempted Village SchoolsNoah's Hope Child Advocacy CenterNord CenterNorth Olmsted School SystemNorth Park Senior LivingNorth Ridgeville School SystemNorth Royalton School SystemNorth Star TherapyNortheast Ohio Neighborhood Health Services, Inc.Northern Ohio Recovery AssociationNorthwest Ohio Juvenile Detention CenterOhio Department of HealthOhio Department of Youth ServicesOhio Hospital For PsychiatryOhio LinkOhio Office of Criminal Justice ServicesOhio State University James Cancer HospitalOhio State University Wexner Medical CenterOhio University - Wilson HallOhioHealth Grant Medical CenterOhioKanOhioRISE-AetnaOhioRISE-CareStarOhioRISE, Cincinnati Children’s HealthvineOhioRise-HarborOhioRISE-Jefferson County Educational Service CenterOhioRISE-PEP (Positive Education Program)OhioRISE- Ravenwood CMEOhioRISE-The Buckeye RanchOhioRISE-Unison HealthOhioRISE-Wingspan Care GroupOhioStartParamountParkview HealthParma City School DistrictPartners for KidsPASSS Post Adoption Special Services SubsityPath CenterPediatric Associates, IncPermanent Family Solutions NetworkPerry County Job & Family ServicesPerrysburg Municipal CourtPickerington SchoolsPortage County Job & Family ServicesPositive Education ProgramPregnant with PossibilitiesProMedica UNSPECIFIEDProvidence HousePsych and Psych ServicesPutnam County Job & Family ServicesQuestRecovery ResourcesRichland County Job & Family ServicesRoss County Job & Family ServicesSandusky County Job & Family ServicesSchool UNSPECIFIEDScioto County Children’s ServicesSelfSeneca County Job & Family ServicesSeneca County Juvenile CourtSignature HealthSouth Central Ohio Job & Family ServicesSouthern District of Ohio - United States District CourtSouthwest General Heath CenterSpringfield Local School DistrictSpringvale Health CentersStark County Family CourtStark County Jobs & Family ServicesStark County Mental Health & Addiction RecoveryStark Board of Developmental DisabilitiesStepstone AcademyStrasburg Franklin ElementaryStrasburg Learning CenterSumma HealthSummit County Children ServiceSummit County Developmental Disabilities BoardSummit County Juvenile CourtSummit County Maternal Depression NetworkSummit County Public HealthSUN Behavioral ColumbusSunrise Vista Behavioral HealthThe Bair Foundation Child & Family MinistriesThe Center for Child & Family AdvocacyThe City MissionThe LCADA WayThe Ohio State UniversityThe Toledo ClinicTreatment Facility UNSPECIFIEDTrumbull County Job & Family ServicesTurning Point Psychotherapy and AssessmentsTuscarawas County Sheriff OfficeTuscarawas County Family and Children First CouncilTuscarawas County Job & Family ServicesTuscarawas County Juvenile CourtUH Rainbow Babies Children's HospitalUMCH Family Services of OhioUnion County Job & Family ServicesUnited Healthcare MedicaidUnited Way UNSPECIFIEDUniversity HospitalUniversity of Toledo Medical CenterVeteran Affairs (VA) UNSPECIFIEDVinton County Job & Family ServicesVisiting Nurse Association of OhioVisiting Physician AssociationVoices for ChildrenVolunteers of AmericaWarren County Job & Family ServicesWashington County Job & Family ServicesWayne County Job & Family ServicesWe Care CrisisWellington Exempted Village School DistrictWestside Community HouseWIC UNSPECIFIEDWilliams County Adult ProbationWilliams County Job & Family ServicesWindsor-LaurelwoodWinterfield Venture AcademyWood County Addiction Response CollaborativeWood County Common Pleas Adult ProbationWood County HospitalWood County Job & Family ServicesWood County Justice CenterWood County Public DefenderWoodlane Residential ServicesWorkforce 360Wyandot County Job & Family ServicesYouth Opportunities UnlimitedZepf CenterOtherPlease begin typing the name of the referral source and select accordingly. If the referral source is not in the drop down, please type "other" and you will be given an option to add it.If Other Referral Source, please specify *Fiscally Responsible CountyReferent Name *FirstLastContact Phone *Referent Email *Program Referred ToProgram LevelSpecific Contract NameComplete if not listed under ProgramReason(s) for Referral (check all that apply) *Medical/PsychiatryRecent Detoxification *Recent Suicidal Ideation/Attempt *Recent Mental Health Hospitalization *Maternal Depression *Alcohol & Drug Abuse Issue *Dual Diagnosis *Mental Health Service NeedsCANSAbuseEmployment ServicesFoster Care NeedsParent Mentoring NeedsAdditional InformationFunder/Payor/ContractPermission obtained to verify benefit eligibility? *YesNoFunding TypeSelf PayMedicaidPrivate InsuranceOther FundingMedicareHousehold Size *Please enter the number of people living in your householdMonthly Gross Income *Please enter the total monthly income amount before taxes for all household membersSource of Income *Medicaid Managed Care Plan *Medicaid Care ID# *Medicaid MMIS# *Private Insurance Company *Employer *Policy Holder Name *Policy Holder Relationship *Policy Holder Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy Holder Social Security Number *Policy Holder Address *Policy Holder Phone *Policy Number *Group *Customer Service Phone Number *Name of Funding Source *Contact Name *Contact Phone *Medicare ID# *Part *MyCare Plan Name *MyCare ID# *Customer Service Phone Number *Nearest OhioGuidestone Region *Please select a regionCrawford/Delaware/Fairfield/Franklin/Licking/Logan/Madison/Marion/Morrow/Pickaway/Richland/Union/WyandotCuyahoga/Geauga/LakeDefiance/Fulton/Hancock/Henry/Lucas/Williams/WoodErie/Huron/LorainMedinaPortage/Stark/SummitTuscarawasService Location Preference *OfficeSchoolCommunityHomeTelehealthService Location Preference *OfficeTelehealthIf you have selected School for your Location Preference and you do not see School District and School options below, we do not offer School Services in your area.School District (Tuscarawas)Select School DistrictNewcomerstown Exempted VillageNew Philadelphia City SchoolsTuscarawas Central CatholicStrasburg-Franklin Local School DistrictGaraway Local SchoolsDover City SchoolsIndian ValleyTuscarawas Valley SchoolsClaymont City SchoolsSchool (Newcomerstown Exempted Village)Select School Newcomerstown High SchoolNewcomerstown Middle SchoolEast ElementaryWest ElementarySchool (New Philadelphia City Schools)Select School Central ElementaryEast ElementaryWelty Middle SchoolNew Philadelphia High SchoolSouth ElementaryWest ElementaryYork ElementarySchool (Tuscarawas Central Catholic)Select School Tuscarawas Central Catholic High SchoolsSchool (Strasburg-Franklin Local School District)Select School Strasburg High SchoolSchool (Garaway Local Schools)Select School Baltic ElementaryDundee ElementaryMiller ElementaryRagersville ElementarySchool (Dover City Schools)Select School Dover AvenueDover MiddleHigh schoolSchool (Indian Valley)Select School Midvale ElementaryPort Washington ElementarySchool (Tuscarawas Valley Schools)Select School Tuscarawas Valley Intermediate SchoolTuscarawas Valley Middle SchoolSchool (Claymont City Schools)Select School Claymont High SchoolClaymont Middle SchoolClaymont Intermediate SchoolClaymont ElementaryClaymont PrimarySchool District (Summit)Select School DistrictAkron Public SchoolsAlternative School APSSchool (Akron Public Schools)Select School Helen Arnold CLCSeiberling CLC ElementaryFindley CLC ElementaryLeggett CLC ElementarySchool (Alternative School APS)Select School Cascade Career Prep High SchoolSchool District (Medina)Select School DistrictBrunswickHighlandBuckeyeBlack RiverSchool (Brunswick)Select School Applewood ElementaryCrestview ElementaryHickory Ridge ElementaryHuntington ElementaryKidder ElementaryMemorial ElementaryTowslee ElementaryBrunswick Middle SchoolBrunswick High SchoolSchool (Highland)Select School Hinckley Elementary SchoolSharon ElementaryGranger ElementaryHighland Middle SchoolHighland High SchoolSchool (Buckeye)Select School Buckeye Primary SchoolBuckeye Intermidate SchoolBuckeye Junior High SchoolBuckeye Senior High SchoolSchool (Black River)Select School Black River Elementary SchoolBlack River Middle SchoolBlack River High SchoolSchool District (Lorain)Select School DistrictAmherst Exempted VillageElyria CityFirelands LocalKeystoneLorain CityLorain County JVSLorain County Community CollegeNorth RidgevilleSheffield/Sheffield LakeCharter/Community SchoolsPrivate SchoolsVermilion Local SchoolsSchool (Amherst Exempted Village)Select School Marion Steele High SchoolAmherst Junior High SchoolNord Middle SchoolPowers ElementarySchool (Elyria City)Select School Eastern Heights Middle SchoolEly Elementary SchoolElyria Early Childhood VillageSchool (Firelands Local)Select School Firelands Elementary SchoolFirelands High SchoolSouth Amherst Middle SchoolSchool (Keystone)Select School Keystone Elementary SchoolKeystone Middle SchoolKeystone High SchoolSchool (Lorain City)Select School General Johnnie Wilson Middle SchoolFrank Jacinto Elementary SchoolLarkmoor Elementary SchoolLongfellow Middle SchoolStevan Dohanos Elementary SchoolWashington Elementary SchoolSchool (Lorain County JVS)Select School Lorain County JVSSchool (Lorain County Community College)Select School Early CollegeSchool (North Ridgeville)Select School North Ridgeville High SchoolNorth Ridgeville Academic CenterLiberty Elementary SchoolNorth Ridgeville Early Childhood 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(Lucas)Select School DistrictToledo Public SchoolsCharter SchoolSpringfield Local SchoolsSchool (Toledo Public School)Select School Garfield ElementaryKeyser ElementarySchool (Charter School)Select School Horizon Science Academy (K-12)School (Springfield Local Schools)Select School Dorr ElementaryHolloway ElementaryHolland IntermediateCrissey ElementarySpringfield Middle SchoolSpringfield High SchoolSchool District (Henry)Select School DistrictNorthwest Ohio Educational Service CenterLiberty Center SchoolsSchool (Northwest Ohio Educational Service Center)Select School Independence Education Center (ESC)School (Liberty Center Local Schools)Select School Liberty Center ElementaryLiberty Center Middle SchoolLiberty Center High SchoolSchool District (Ottawa)Select School DistrictGenoa Local SchoolsSchool (Genoa Local Schools)Select School Genoa High SchoolGenoa Middle SchoolSchool District (Williams)Select School DistrictBryan City School DistrictSchool (Bryan City School District)Select 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High School ParmaCitizens Academy Glenville (K-5)Citizens Leadership Academy Glenville (6-8)Citizens Academy Southeast (K-5)Citizens Leadership Academy Southeast (6-8)Flex High SchoolGlobal Ambassadors Language AcademyGeorge Voinovich Career Tech High SchoolInnovation Academy WestIntergenerational Near WestLakeshore Intergenerational SchoolThe Intergenerational School EastLake Erie International High SchoolLincoln Park Academy LowerLincoln Park Academy UpperNorthwest School of the ArtsParma AcademySt John Nottingham Lutheran SchoolStepstone AcademyUrban Community SchoolVillage Prep Cliffs CampusVillage Prep Willard CampusVillage Prep Woodland CampusSchool (Cleveland Metropolitan School District)Select School CMSD Remote High SchoolArtemus WardBuhrer Language AcademyDesign LabDouglas MacArthur Girls Leadership AcademyGinn AcademyJames GarfieldJames Rhodes School of Environmental StudiesJames Rhodes College and Career AcademyJohn Marshall High School of EngineeringJohn Marshall School of Business & Civil LeadershipJohn Marshall School of Information TechnologyJoseph M GallagherKenneth Clement Boys Leadership AcademyLincoln West School of Global StudiesLincoln West School of Science and HealthMcStem School @ CSUMcStem School @ Tri-CMcStem School @ Great Lakes Science CenterNathan HaleNew Tech WestOliver H PerryTremont MontessoriWilliam C BryantWilliam Rainey HarperSchool (East Cleveland)Select School Caldonia Elementary SchoolKirk Middle SchoolMayfair Elementary SchoolShaw High SchoolSuperior School for the Performing ArtsSchool (Euclid City Schools) Select School Arbor Elementary SchoolsBluestone ElementaryChardon Hills Stem SchoolEuclid Middle SchoolEuclid High SchoolSchool (Garfield Heights City Schools) Select School Elmwood Elementary SchoolGarfield Heights High SchoolGarfield Heights Learning CenterGarfield Heights Middle SchoolMaple Leaf Elementary SchoolWilliam Foster Elementary SchoolSchool (Lakewood City Schools)Select School Emerson Elementary SchoolHarrison Elementary SchoolHayes Elementary SchoolRoosevelt Elementary SchoolSchool (Olmsted Falls City Schools) Select School Olmsted Falls High SchoolOlmsted Falls Middle SchoolOlmsted Falls Intermediate SchoolFalls Lennox Primary SchoolEarly Childhood Learning CenterSchool (Parma City Schools) Select School Dentzler Elementary SchoolGreen Valley Elementary SchoolGreenbriar Middle SchoolHillside Middle SchoolJohn Muir Elementary SchoolNormandy High SchoolParma Park Elementary SchoolParma Senior High SchoolPleasant Valley Elementary SchoolRenwood Elementary SchoolRidge-Brook Elementary SchoolShiloh Middle SchoolThoreau Park Elementary SchoolValley Forge High SchoolSchool (Parochial Schools) Select School Luther Memorial SchoolLutheran East High SchoolSt. Francis SchoolSt. Rocco SchoolSchool (Richmond Heights Local Schools)Select School Richmond Heights Elementary SchoolRichmond Heights Middle SchoolRichmond Heights High SchoolSchool (South Euclid Lyndhurst City Schools)Select School Adrian 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Sherman Junior High SchoolTarhe Trails Elementary SchoolTallmadge Elementary SchoolMount Pleasant Elementary SchoolLancaster High SchoolGorsuch West ElementaryMedill ElementarySchool (Berne Union School District)Select School Berne Union Elementary SchoolBerne Union High SchoolSchool (Pickerington City School District)Select School Tussing Elementary SchoolPickerington Alternative SchoolPickerington High School CentralPickerington High School NorthLakeview Junior HighRidgeview STEM Junior HighDiley Middle SchoolHarmon Middle SchoolToll Gate Middle SchoolFairfield Elementary SchoolHeritage Elementary SchoolPickerington ElementarySycamore Creek Elementary SchoolToll Gate Elementary SchoolViolet Elementary SchoolSchool (Fairfield Union School District)Select School Bremen ElementaryPleasantville ElementaryRushville Middle SchoolFairfield Union High SchoolSchool (Bloom Carroll School District)Select School Bloom Carroll PreschoolBloom Carroll ElementaryBloom Carroll Middle SchoolBloom Carroll High SchoolSchool (Amanda Clearcreek Local School District)Select School Amanda Clearcreek Primary SchoolAmanda Clearcreek Elementary SchoolAmanda Clearcreek Middle SchoolAmanda Clearcreek High SchoolSchool (Fairfield County ESC)Select School Prep for SuccessSuccess CenterSchool (Liberty Union School District)Select School Liberty Union ElementaryLiberty Union Middle SchoolLiberty Union High SchoolSchool District (Franklin)Select School DistrictHamilton Local School DistrictWhitehall City School DistrictKIPP ColumbusSchool (Hamilton Local School District)Select School Hamilton Township High SchoolHamilton Middle SchoolHamilton Intermediate SchoolHamilton Elementary SchoolHamilton PreschoolSchool (Whitehall City School District)Select School Whitehall-Yearling High SchoolRosemore Middle SchoolBeechwood Elementary SchoolEtna Road Elementary SchoolKae Avenue Elementary SchoolSchool (KIPP Columbus)Select School KIPP Columbus HighKIPP Columbus MiddleKIPP Columbus ElementaryKIPP Columbus PrimarySchool District (Licking)Select School DistrictGranville Exempted Village SchoolsSchool (Granville Exempted Village Schools)Select School Granville High SchoolGranville Middle SchoolGranville Intermediate SchoolGranville Elementary SchoolSchool District (Madison)Select School DistrictWest Jefferson Local School DistrictSchool (West Jefferson Local School District)Select School West Jefferson High SchoolWest Jefferson Middle SchoolNorwood Elementary SchoolSchool District (Marion)Select School DistrictPleasant Local School DistrictMarion City School DistrictRidgedale Local SchoolsRiver Valley Local SchoolsElgin Local SchoolsSchool (Pleasant Local School District)Select School Pleasant Elementary SchoolPleasant Middle SchoolPleasant High SchoolSchool (Marion City School District)Select School Harding High SchoolGrant Middle SchoolBenjamin Harrison Elementary SchoolGarfield Elementary SchoolHayes Elementary SchoolGeorge Washington Elementary SchoolTaft Elementary SchoolMcKinley Elementary SchoolSchool (Ridgedale Local Schools)Select School Ridgedale Elementary SchoolRidgedale Jr./Sr. High SchoolSchool (River Valley Local Schools)Select School Liberty Elementary SchoolHeritage Elementary SchoolRiver Valley Middle SchoolRiver Valley High SchoolSchool (Elgin Local Schools)Select School Elgin Elementary SchoolElgin Middle SchoolElgin High SchoolGradeTeacherYou may cc an OhioGuidestone staff by entering their email belowIf you'd like, you can PRINT A COPY OF THIS RECORD before submitting this form. 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