Skip links
Skip to primary navigation
Skip to content
Phone: (440) 310-6361
admin@holdingspacecle.com
REQUEST AN APPOINTMENT
Toggle navigation
About
Fees For Service
What To Expect
Our Team
Brecksville Office Team
Westlake Office Team
Approach
Services
Clinical Supervision
Individual Therapy
Maternal-Infant Mental Health
Play and Art Therapy
Teletherapy
Specialties
Anxiety and Depression
Parenting Education/Support
Perinatal Mental Health
Pregnancy Loss and Infertility
Contact
Building Blocks Registration
Please enable JavaScript in your browser to complete this form.
Child's Name
*
First
Last
Date of Birth
*
Parent/Guardian Name
*
First
Last
Layout
Parent/Guardian Contact Email
*
Insurance type
*
Insurance Group Number
*
Phone
*
Insurance ID number
*
What are the goals you hope your child will accomplish by participating in this group?
*
Layout
Emergency Contact
*
Emergency Contact Phone
*
Emergency Contact(Required) Relationship
*
Does your child have any allergies? If YES, please describe
*
Is your child a holding space client?
*
Yes
No
Submit