New Client Intake

Let's begin.

A short, secure form to start care in Ohio — in person at our Ohio office or by secure telehealth video. Please do not include sensitive clinical or health details here; we'll discuss those privately during your consultation.

Step 1 of 2 · Medicaid eligibility check

Can we bill your Ohio Medicaid plan?

NobleMind is a Medicaid-based practice. Confirm your plan and member ID and we'll tell you right away whether we can bill your Ohio Medicaid coverage directly. Don't have Medicaid? You can skip this step.

About you

Full name

Phone (optional)

Preferred contact

What you're looking for

Area of focus

Insurance provider (optional)

Session format

Telehealth requires you to be physically located in Ohio at the time of each session.

Anything you'd like us to know before we reach out?

Please keep this general — avoid clinical or health details.

ConsentI understand this form is for scheduling only, that NobleMind is not an emergency service, and that I should not include sensitive health details here. I have read the Privacy Policy and HIPAA Notice.If choosing telehealth: I understand that telehealth visits use a HIPAA-compliant video platform, that I must be physically located in Ohio at the time of each session, and that telehealth carries additional risks (technology interruptions, limited ability to respond to in-room emergencies). Required only if you selected telehealth above.

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