Request Services

How to Request Services from OhioGuidestone 

Please complete the form below to request services from OhioGuidestone. An Intake Specialist will contact you by phone within two business days of receiving your request.  

If you are in need of a same day appointment, please use our ReadyCare Walk-In Clinics for Behavioral Health or our Primary Care Services (in Lorain County only). If you are having a medical emergency, please call 911 or if you are having a mental health crisis, please call 988 (National Suicide Hotline).

OhioGuidestone Request for Services Form

Who is filling out this form?
Client Information
Date of Birth
Gender
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.
Do you give permission to receive text messages for scheduling purposes if you have shared your cell phone number below?
What type of phone is this?
Marital Status
Race
Ethnicity
County Worker Name, if applicable
For clients involved with Children’s Services
Reason(s) for Referral (check all that apply)
If you are in need of a same day appointment, please use our ReadyCare Walk-In Clinics for Behavioral Health or our Primary Care Services (in Lorain County only). If you are having a medical emergency, please call 911 or if you are having a mental health crisis, please call 988 (National Suicide Hotline).

Funder/Payor/Contract

Permission obtained to verify benefit eligibility?
Funding Type
Service Location Preference

If you’d like, you can PRINT A COPY OF THIS RECORD before submitting this form. You can also request a copy from your OhioGuidestone provider.

Next Steps 

After you submit our Request for Services form, an Intake Specialist will assist you in taking the first steps by determining where you live, your availability, your specific needs and connecting you with a skilled professional who is best able to assist you.   

What does this form do?

This form tells us what your needs are and helps us connect you with the right people as quickly as possible. At OhioGuidestone, we provide a complete continuum of prevention services and mental health and substance use treatment services throughout the state. This form helps us connect you with the right people and takes away the guess work.  

Who should complete the form?

This form can be filled out by a person in need of services or someone requesting services on behalf of that person (parent, guardian, legal caretaker, health care or insurance provider, etc.  Please note we may ask for related legal documentation).