Adult Waitlist

Welcome to COAC! Please complete this confidential form to provide important information and to make sure that we are the best fit for your needs.
Interested in treatment at COAC? Please select your highest priority for treatment to get started.*
This form is for adult patients only. Please click on Get Started above and select the child/adolescent form.
How did you hear about us?*
Please explain "Other"
Who referred you?
Please select your insurance plan, or if you are out of network*

I am out of network, but would like to self-payAetnaAetna AdvantageCignaMedical MutualOhioHealthyDevoted Health
Please note the following self-pay fees, and select the option that works best for you:*

Psychologist (45 Min: $220; 60 Min: $285)Licensed Clinical Therapist (45 Min: $185; 60 Min: $265)Dr. Free, Owner (45 Min: $285; 60 Min: $325)First Available
Please select your preference:*

Telehealth onlyPrefer TelehealthOpen to eitherPrefer in-personIn-person only
If you will be seeking Telehealth services while physically in any other state than Ohio, please list any and all states that may apply (excluding brief trips, vacations, etc.)
I am out of network, and would like to receive documentation (i.e., Superbills) to file my own insurance claims.*

YesNo
Name*

First NameLast Name
Birth Date:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please provide the best times to reach you over the next two business days.
Do we have permission to contact you after 8 PM?

YesNo
Please describe the primary reason you are seeking treatment:*

0/250
My upbringing or family circumstances growing up has affected me ________.*
I experience repetitive and unwanted thoughts, mental images, or impulses (i.e., obsessions) that cause distress or anxiety.*

Not a problemMildModerateSeverePrefer not to answer
I feel compelled to perform repetitive behaviors or mental acts (i.e., compulsionsto reduce anxiety, or to stop something bad from happening.*

Not a problemMildModerateSeverePrefer not to answer
I experience excessive, uncontrollable worry about everyday things much of the time.*

Not a problemMildModerateSeverePrefer not to answer
I frequently experience intense anxiety in social situations, such as meeting new people, speaking in public, or participating in group activities. Social anxiety interferes with my daily life.*

Not a problemMildModerateSeverePrefer not to answer
I experience intense fear or anxiety when exposed to particular objects, situations, or activities (e.g., such spiders, heights, flying, animals/insects, needles) that interferes with my life.*

Not a problemMildModerateSeverePrefer not to answer
I frequently worry about panic or anxiety attacks, and/or I avoid situations that specifically due to fear of having a panic attack.*

Not a problemMildModerateSeverePrefer not to answer
I experience excessive anxiety in situations where it may be difficult to escape or may be embarrassing to have distressing symptoms (e.g., panic attack, vomiting, diarrhea).*

Not a problemMildModerateSeverePrefer not to answer
I worry a lot about developing a serious illness (e.g., cancer) or about certain physical symptoms that I am experiencing.*

Not a problemMildModerateSeverePrefer not to answer
I pick my skin or pull out my hair and find it very hard to stop.*

Not a problemMildModerateSeverePrefer not to answer
I am very preoccupied with perceived flaws in my appearance that are insignificant or not noticeable to others.*

Not a problemMildModerateSeverePrefer not to answer
I experience sudden movements (e.g., tics) or make sounds that are hard to control.*

Not a problemMildModerateSeverePrefer not to answer
For the past two weeks, I have felt sad/down or am much less interested in things I typically enjoy more often than not.*

Not a problemMildModerateSeverePrefer not to answer
I have been diagnosed with bipolar disorder, or I think I might have had a manic episode.*

YesNoPrefer not to answer
I have experienced or witnessed a traumatic event that continues to cause me distress or interfere with my daily life.*

Not a problemMildModerateSeverePrefer not to answer
I have persistent problems related to food intake and/or body weight that interferes with my life (e.g., fear of gaining weight, food restriction, binging/purging, or weigh less than others think I should).*

Not a problemMildModerateSeverePrefer not to answer
In the past 6 months, I have been hospitalized for a psychological issue or problem (e.g., inpatient hospitalization, IOP, PHP)*

YesNoPrefer not to answer
At some point in the past year, I have regularly (e.g., daily/weekly) used substances other than alcohol or I have used prescription medications in ways that were not prescribed.*

Not a problemMildModerateSeverePrefer not to answer
My substance use habits cause problems, interfere with my life, or cause concern for my family/friends.*

Not a problemMildModerateSeverePrefer not to answer
I consume approximately _____ number of alcoholic beverages per week.
My drinking habits cause problems, interfere with my life, or cause concern for my family/friends.*

Not a problemMildModerateSeverePrefer not to answer
With the right kind of treatment, I think I could make progress with improving my mental health.*

YesNo
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