Request to transfer to a different therapist

Request to transfer to a different therapist

for current patients at CBH only
This information will be shared with your therapist and they will facilitate the transfer process. Please know that the therapist you are referred to will conduct an assessment during your first meeting to confirm that they can meet your needs and provide appropriate care. A plan for your treatment moving forward will be determined in that appointment.
Today's date*

MonthDayYear
Date
Patient's Name*

First NameLast Name
Patient's date of birth*
Patient's age*
Name of therapist patient is currently seeing*
Which type of referral do you prefer? (internal transfers are not guaranteed; subject to availability and specialization)*

Internal- another therapist at Columbus Behavioral HealthExternal- therapist at another practice
Do you have a gender preference for therapist?*

No, doesn't matterYes, femaleYes, male
Is there a specific therapist you are wanting to see?*

YesNo
If yes, which therapist? (not guaranteed; subject to availability and specialization)
Briefly describe the reason(s) you would like to change therapists*
Have you already discussed your desire to change therapists with your current therapist?*

YesNo
If not, why not?
This information will be shared with your therapist and they will facilitate the transfer process. Please know that the therapist you are referred to will conduct an assessment during your first meeting to confirm that they can meet your needs and provide appropriate care. A plan for your treatment moving forward will be determined in that appointment.

If no internal therapists are available or appropriate, an external referral will be provided.

Your therapist will reach out to you to discuss next steps.
Should be Empty: