Contact Gro Community Have a question? We’d love to connect! Just fill out this form and we’ll contact you within 48 hours Psychiatric New Inquiry Form What is your relationship to the Client * -None- Self Parent/Guardian Other Client's Gender * -None- Male Female Client's First Name * Client's Last Name * Client's Date of birth * Emergency Contact Name/Parent's Name (if a minor) * Phone * Email (Parent's email if a minor) * City * Zip Code * Insurance Provider * -None- Blue Cross Blue Shied of IL PPO Cigna Behavioral Health IL PPO United Healthcare IL PPO County Care (IL Medicaid) OhioRISE/Aetna (OH Medicaid) Anthem BCBS (OH Medicaid) Blue Cross Community (IL Medicaid) Aetna Better Health (IL Medicaid) Meridian (IL Medicaid) Molina (IL Medicaid) YouthCare (IL Medicaid) Molina Healthcare (OH Medicaid) United Healthcare Community Plan (OH Medicaid) CareSource (OH Medicaid) Humana Healthy Horizons (OH Medicaid) Buckeye Health Plan (OH Medicaid) No active insurance Other not listed Upload copy of Insurance File(s) size limit is 20MB. Describe your concerns * Best Time of Day to Contact You * -None- Mornings (8am-12pm CT) Afternoons (12-4pm CT) Evenings (4pm-7pm CT) No preference Preferred Method of Communication * -None- Phone call Text Email SMS Consent Confirmation -None- Yes, I consent to receive SMS messages regarding services, appointment reminders and program updates. No, I do not consent to receive SMS messages. SMS Message Opt-In Disclaimer: By submitting this form, you consent to receive text messages from GRO Community at the number provided regarding your inquiry, appointments, and services. Messages may include confirmations, intake coordination, and appointment reminders. Consent is not a condition of purchase. Msg & data rates may apply. Message frequency varies. Reply STOP to opt out or HELP for assistance. No phone information will be shared or sold. View Terms of Service View Privacy Policy Please accept this Partner School/Community Org (if applicable) Enter the Captcha Reload Client Leads Status -None- Contact Attempt 1 Junk Lead/Not Eligible for Services New Inquiry Screening Complete Clinical Assessment Complete Discharged (No longer a client) Closed- Declined Services Not Eligible for Services Disqualified Second Attempt No Response after 3 Attempts Client Leads Source -None- ClearChannel Billboards COR-20260130-001 FAM-20260219-001 (Family Services Weborm) GCCIN-20260204-001 (Cincinnati Webform) GCCLE-20260204-001 (Cleveland Webform) GCCOL-20260204-001 (Columbus Webform) GCDAY-20260218-001 (Dayton Webform) Google AdWords GRO Community website JCDeaux LinkedIn School Based Campaign Meta Ads PRB-20260204-001 (Probation Webform) PSY-20260326-001 (Psychiatric Webform) Public Relations RadioOne Ohio radio ads RCAR-20260204-001 (Carbondale/Southern IL Webform) RNY-20260204-001 (Reentry Webform) RPEO-20260204-001 (Peoria/Central IL Webform) RPEO-20260212-001 (Springfield Webform) RROC-20260204-001 (Rockford/Northern IL Webform) RWAU-20260204-001 (Waukegan Webform) SNC-20260204-001 (School Webform) SNC-20260204-002 (Community Webform)
