Request an Appointment

Thank you for your interest in making an appointment at Cleveland Rape Crisis Center.

Please fill out the following information, and we will contact you within 1-2 business days to connect you with our services and answer any questions you may have. You may use this form to request an appointment at any of our locations in Cuyahoga County, Lake County, Geauga County or Ashtabula County, or simply call  (216) 619-6194, ext. 141.

Please be advised that due to HIPAA and confidentiality laws we cannot contact adults without their consent. If you are a parent, teacher or other caring adult for a survivor over 18, please do not fill out this form without their knowledge and full agreement.

If you need immediate assistance during business hours, feel free to call us at (216) 619-6194 or, anytime of the day or night, contact our 24-hour crisis and support hotline at (216) 619-6192 or (440) 423-2020 for assistance and support.

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Request an appointment