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.
MyselfSomeone else
YesNo, the patient is a minor
You are currently on the Adult interest form. For children and adolescents, we need a bit of different information to make sure we understand your child’s needs.

Please return to the top of the page and click “Get Started” to access the Child/Adolescent interest form. We look forward to learning more about how we can help.
Name of the person completing this form*

First NameLast Name
What is your relationship to the patient?*
Phone number of the person completing this form*
Please enter a valid phone number.Format: (000) 000-0000.
Email address of the person completing this form*
example@example.com
Please select your highest priority for treatment.*
How did you hear about us?*
Please explain "Other"
Who referred you?
I am out-of-network, but would like to self-payAetnaAetna AdvantageCignaMedical MutualOhioHealthyDevoted Health
Psychologist (45 Min: $220; 60 Min: $285)Licensed Clinical Therapist (45 Min: $195; 60 Min: $285)Dr. Free, Owner (45 Min: $295; 60 Min: $325)First Available
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.)
YesNo
Patient's Name*

First NameLast Name
Patient's Birth Date:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Please provide the best times to reach you over the next two business days.
YesNo
Please describe the primary reason you are seeking treatment:*

0/250
My upbringing or family circumstances growing up has affected me ________.*
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
YesNoPrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
YesNoPrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
Not a problemMildModerateSeverePrefer not to answer
I consume approximately _____ number of alcoholic beverages per week.
Not a problemMildModerateSeverePrefer not to answer
YesNo
Should be Empty: