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.

Are you seeking treatment for yourself or someone else?

Is the prospective patient at least 18 years old as of today?

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?

Please select your insurance plan, indicate that you will be self-pay.

Please note the following self-pay fees, and select the option that works best for you:

Please select your preference:

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.

Patient's Name

First NameLast Name

Patient's Birth Date:

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.

Do we have permission to contact you after 8 PM?

Please describe the primary reason you are seeking treatment:

0/250

My upbringing or family circumstances growing up has affected me ________.

Obsessions: I experience repetitive and unwanted thoughts, mental images, or impulses that cause distress or anxiety.

Compulsions: I feel compelled to perform repetitive behaviors or mental acts to reduce anxiety, or to stop something bad from happening.

Worry: I experience excessive, uncontrollable worry about everyday things much of the time.

Social Anxiety: 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.

Phobia: 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.

Panic: I frequently worry about panic or anxiety attacks, and/or I avoid situations that specifically due to fear of having a panic attack.

Agoraphobia: 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).

Illness Anxiety: I worry a lot about developing a serious illness (e.g., cancer) or about certain physical symptoms that I am experiencing.

BFRBs: I pick my skin or pull out my hair and find it very hard to stop.

BDD: I am very preoccupied with perceived flaws in my appearance that are insignificant or not noticeable to others.

Tics: I experience sudden movements (e.g., tics) or make sounds that are hard to control.

MDD: For the past two weeks, I have felt sad/down or am much less interested in things I typically enjoy more often than not.

BD: I have been diagnosed with bipolar disorder, or I think I might have had a manic episode.

Trauma: I have experienced or witnessed a traumatic event. I have frequent symptoms of PTSD that currently causes problems in my life.

ED: 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).

In the past 6 months, I have been hospitalized for a psychological issue or problem (e.g., inpatient hospitalization, IOP, PHP)

SUD: 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.

SUD: My substance use habits cause problems, interfere with my life, or cause concern for my family/friends.

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.

With the right kind of treatment, I think I could make progress with improving my mental health.