ADAM CENTER INTAKE APPLICATION

To receive counseling or to schedule an appointment:

  • Please call the Office (513) 729-7008 for a 20 minute telephone conversation to complete intake information for matching you with a Volunteer Peer Counselor.

  • Adam Center, LLC does not guarantee complete confidentiality of any information sent electronically.

A completed applications is required to be filled out prior to seeing a peer counselor.

 You may complete this online application.  It will be sent to the Director when you click “send email” at the end of the form below:

Today's Date *
Today's Date
Applicant's Name *
Applicant's Name
Address
Address
Phone
Phone
Marital Status