CCWHC
Crisis: 330-264-9029
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For Patients
​
Medicaid Renewals
Forms
Links
Tid Bits
B4Stage4
​
   Risky Business
Fact Sheet
​    Caregivers
     Young Adults ​
Payment and Billing
Genoa Pharmacy

Forms

The form groups listed below.will be available shortly for clients to use prior to appointments. 

Intake

Confidentiality
Consent for Treatment
​Contact Preferences
Fee Determination
​Notice of Eligibility
Residency Verification 
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Release of Information

Release of Information 

Outcomes

PHQ-9
GAD-7
Quality of Life Scale
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Other

Healthcare Power of Attorney
Telhealth 
​Client Satisfaction Survey
All photographs are compliments of our Counseling Center "family and friends". Enjoy the talent!
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The Counseling Center of Wayne and Holmes Counties
2285 Benden Drive
Wooster, OH 44691
Main Office: (330) 264-9029
Toll Free: (877) 264-9029
Fax: (330) 263-7251 
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