Welcome to Proven Pathways!
Please fill out our confidential form so we can learn more about you. This will help us have a conversation with you about our practice and how we could address your needs. We will return your contact within one business day. If you would prefer to have a brief conversation with us before completing this form, please feel free to call 614-594-9360.
How did you hear about our practice?
What kind of therapy do you prefer?
In person only
Prefer in person
Telehealth only
Prefer telehealth
Open to telehealth or in person
If you will be seeking telehealth services while physically in a state other than Ohio, please list any and all states that may apply (excluding brief trips, vacations, etc.)
Dr. Conklin accepts self-pay only and can create superbills for out-of-network coverage. She will be able to accept insurance soon. Dr. Free accepts self-pay and the below insurances. Please check your insurance and we can have a discussion with you about what to expect:
Aetna
Aetna Advantage
Cigna
Humana
Humana Medicare
Medical Mutual
OhioHealthy
Devoted Health
None of the above, open to self-pay
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please provide the best times to reach you.
Please briefly describe the primary reason you are seeking treatment:
For the past two weeks, I have felt sad, down, depressed, or am much less interested in things I would typically enjoy.
Not a problem
Mild
Moderate
Severe
I have been diagnosed with bipolar disorder, or think I might have had a manic episode.
Yes
No
I experience significant irritability and anger, and it interferes with my life.
Not a problem
Mild
Moderate
Severe
I have experienced or witnessed a traumatic event that often causes distress and currently interferes with my daily life.
Not a problem
Mild
Moderate
Severe
I experience excessive, uncontrollable worry about a variety of everyday topics.
Not a problem
Mild
Moderate
Severe
I frequently feel intense anxiety in social situations, such as meeting new people, speaking in public, or participating in group activities, and it interferes with my life.
Not a problem
Mild
Moderate
Severe
I experience intense fear or anxiety when exposed to particular objects, situations, or activities (e.g., spiders, heights, flying, animals/intects, needles) that interferes with my life.
Not a problem
Mild
Moderate
Severe
I have frequent panic attacks or go out of my way to avoid having a panic attack.
Not a problem
Mild
Moderate
Severe
I rarely leave my home unless I'm with a loved one, or I find it very difficult to be in public due to anxiety or panic attacks.
Not a problem
Mild
Moderate
Severe
I experience repetitive and unwanted thoughts, mental images, or impulses that cause distress or anxiety.
Not a problem
Mild
Moderate
Severe
I feel compelled to perform repetitive behaviors or mental acts to reduce anxiety, or to stop something bad from happening.
Not a problem
Mild
Moderate
Severe
I worry a lot about developing a serious illness (e.g., cancer) or about certain physical symptoms that I am experiencing.
Not a problem
Mild
Moderate
Severe
I pick my skin or pull out my hair and find it hard to stop.
Not a problem
Mild
Moderate
Severe
I am preoccupied with perceived flaws in my appearance that are insignificant or not noticeable to others.
Not a problem
Mild
Moderate
Severe
I experience sudden movements (e.g., tics) or make sounds that are hard to control.
Not a problem
Mild
Moderate
Severe
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, intentional vomiting, or weigh less than others think I should).
Not a problem
Mild
Moderate
Severe
In the past year, I have regularly (e.g., daily/weekly) used illegal drugs or prescription medications in ways that were not prescribed.
Yes
Not regularly, but periodically
No
My drug habits cause problems, interfere with my life, or cause concern for my family/friends.
Not a problem
Mild
Moderate
Severe
I consume approximately ___ alcoholic beverages per week (insert estimate).
My drinking habits cause problems, interfere with my life, or cause concern for my family/friends.
Not a problem
Mild
Moderate
Severe
In the past 6 months, I have participated in the following treatment for my mental health:
Therapy (outpatient)
Psychiatric medication management
Intensive outpatient treatment (IOP)
Partial hospitalization program or day program (PHP)
Residential treatment
Inpatient mental health treatment
Other
With the right kind of treatment, I think I could make progress with improving my mental health.
Yes
No
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