Name * First Name Last Name Email * Phone (###) ### #### I am a resident and currently live in the state of Ohio. * Yes No Which service are you interested in? * Therapy with Emily Therapy with Katlyn Therapy with Either Clinician QPR Classes Comprehensive Mental Health/ Substance Use Assessment Wellness Visit for First Responders Would you like a 15 minute Free consult? * Yes No How did you hear of us? Social Media Word of Mouth Professional Referral Psychology Today Other Message * Self-Pay Acknowledgement * I understand that Ember Wellness & Counseling does not accept insurance at this time. This service is self-pay at a rate of $130 a session (0-55 minutes). Yes Thank you for reaching out. We will be in contact within 48 business hours. If you are currently in crisis please immediately contact 911 or 988 - National Suicide & Crisis Lifeline, or visit your local emergency department. Interested in working together? Tell us about yourself and we will be in touch shortly! We can't wait to hear from you! Let’s work together CALL 513-409-1320
