A few questions first...
Depending upon the therapist selected (and whether you are using insurance, or are going to be self-pay), we will have you complete different intake paperwork
Which therapist are you scheduling with?
Please Select
Megan Beebe, LISW (Northwoods Central)
Bria Ewing, LPCC (Northwoods Central)
Jessica Evans, LISW-S (Northwoods Central)
Alexandra Gilbert, LISW (Northwoods Central)
Danielle Maas, LISW-S (Northwoods Central)
Mark Travis, LPCC-S (Northwoods Central)
Colleen Barrows, LPCC (Northwoods Delaware)
Paula Clay, LPCC-S (Northwoods Delaware)
Keeli Cook, LPCC (Northwoods Delaware)
Marjan Cuckler, MSW, LSW (Northwoods Delaware)
Kellie Dawson, LISW-S (Northwoods Delaware)
Todd Fry, LISW-S (Northwoods Delaware)
Jordan Hambrick, LPCC (Northwoods Delaware)
Carrie Hartsock, LISW-S (Northwoods Delaware)
Jenni Longo, LISW(Northwoods Delaware)
Denise Williams, LPCC-S
Cecilia Monahan, LPC (Northwoods Delaware)
(Note: If you are needing to schedule with Jenilee Accurso, PhD, Samantha Leeman, MA, Lexi Myers, MA, you should complete form associated with their bio on the bio page)
Insurance companies that Northwoods Clinic is in contract with are the following:
Aetna (*note: not Aetna through the State of Ohio-they use UBH for mental health. Please examine your card carefully)
ChoiceCare
Cigna
First Health (Includes Coventry Health Care)
HealthSmart (Includes: AHPO, Emerald and Interplan)
Humana (GE Health Care Preferred, Humana / ChoiceCare National PPO, Humana National POS Open Access, P&G National POS, US Bank PPO)
Medical Mutual of Ohio/SuperMed
Ohiohealth's Healthy Med Plan (managed by Optima)
Ohio Health Choice (Includes the following payers:
Ohio Health Choice Site
)
Zelis Healthcare (formerly Stratose; includes Ohio Preferred Network [OPN])
Are you planning to use an insurance plan that is contracted with Northwoods Clinic?
Yes
No
Since you chose "No" ...
It is important to note that Northwoods Clinic is only paneled and contracted with the above listed insurance plans. If you have a different insurance, you are going to need to communicate directly with the therapist to see if that are individually on panel with your plan, or will you end up being "self-pay."
Rates are individually determined, so you will need to contact them directly for that information.
Please indicate which category of client you are for Ms. Longo
I'm a parent/guardian of a minor client (17 or younger)
I'm a parent/guardian of a young adult client (18+)
I'm the client, and I'm a minor (17 or younger)
I'm the client, and I'm a young adult
Please indicate which category of patient you are for your prescriber
The patient is a child younger than 12
The patient is an adolescent between the age of 12 & 18
The patient is an adult
Northwoods Clinic Therapist
Northwoods Clinic Intake Paperwork
Therapist's Private Practice
Therapist's Private Practice Intake Paperwork
Jenni Longo's Parents/Guardian of Minors (17 or younger) Northwoods Clinic Intake Paperwork
Jenni Longo's Parents/Guardian of Minors (17 or younger) Private Practice Intake Paperwork
Jenni Longo's Northwoods Clinic 17 or younger Adolescent Intake Form
Jenni Longo's Private Practice 17 or younger Adolescent Intake Form
Jenni Longo's 18 and older Northwoods Clinic Intake Paperwork
Jenni Longo's 18 and older Private Practice Intake Paperwork
Jenni Longo's Parents/Guardian of Young Adults (18+) Northwoods Clinic Intake Paperwork
Prescriber (Over 12) Northwoods Clinic Intake Paperwork
Prescriber (Under 12) Northwoods Clinic Intake Paperwork
Prescriber Adult Northwoods Clinic Intake Paperwork
Prescriber Private Practice Adult Intake Paperwork
Prescriber Private Practice Intake Paperwork for Children over age 12
Prescriber Private Practice Intake Paperwork for Children under age 12
Should be Empty: