Let's Get Started — Champion Healthcare Services

Let’s Progress to Success Together

Welcome to Champion Healthcare Services! Everything in life is a process but process is simple! Please complete the following information and a representative from the Champion family will contact you to schedule your first appointment with one of our Therapy Specialists.

Name

First Name

Last Name

Person Needing Our Services Is a...

Child

Adult

Gender

Male

Female

Race

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Social Security Number

Name of School (if applicable)

School Grade (if applicable)

Parent/ Guardian/ Person Legally Responsible for the Minor (if applicable)

Services you are interested in receiving more information about

Please check all that apply

BEHAVIORAL HEALTH SERVICES

INDIVIDUAL THERAPY

GROUP THERAPY

COMMUNITY PSYCHIATRIC SUPPORT TEAM

Who is your current Mental Health Provider?

Your Insurance Provider

Please describe problems or concerns

How did you hear about us? Who Referred You?

Let’s Progress to Success Together

513.766.9418 office I 513.586.0914 fax

OFFICE LOCATIONS

201 E. 5th Street Suite 1900

600 Superior Ave. E.Suite 1300

Behavioral Health Services

Individual Therapy

Group Therapy

Community Psychiatric Support Team

Anger Management Therapy

Cognitive Behavioral Therapy

CHAMPIONHCS.COM

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