Welcome to Proven Pathways!
Please fill out our confidential form so we can learn more about you and your child/adolescent. This will help us have a conversation with you about our practice and how we could best address your needs. We will endeavor to return your contact within one business day.
How did you hear about our practice?
We offer both in person and Telehealth services to clients in Ohio. 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.)
Please check your insurance and we can have a discussion with you about what to expect (Note for state employees: while your card says Medical Mutual, you likely have Optum for behavioral health, which we are not in network with):
I am out of network, but would like to self-pay
Aetna
Meritain
Cigna
Medical Mutual
OhioHealthy
Tricare (we are a certified out-of-network provider)
Do you have a Medicaid insurance plan or a dual-eligible Medicare/Medicaid plan OR do you plan to apply for one of these plans in the next 6 months?
Yes
No
Name of person completing this form (typically a parent, caregiver, or other adult)
First Name
Last Name
Phone number of person completing this form
Please enter a valid phone number.
Format: (000) 000-0000.
Email of person completing this form
example@example.com
Your relationship to the child/adolescent
Are you the child/adolescent's legal guardian?
Yes
No
Name of child/adolescent
First Name
Last Name
Age of child/adolescent
Please Select
8
9
10
11
12
13
14
15
16
17
Date of Birth of child/adolescent
-
Month
-
Day
Year
Date
Please provide the best times to reach you today and tomorrow. If you're completing this form over the weekend, please list your availability for Monday and Tuesday.
Does the child/adolescent have a second parent or legal guardian (If yes, please list the full name and contact information for the second parent/legal guardian).
The child/adolescent has a custody agreement/order in effect or is expected to have a custody agreement/order in effect in the next 12 months.
Yes
No
Please describe the main concerns that led you to seek treatment for your loved one. Briefly describe the symptoms they are experiencing and how those symptoms are impacting their functioning at home, school/work, or socially.
Does your loved one have a history of any of the following? Please check all that apply.
Rows
Yes
No
Unsure or Not Diagnosed Formally
Depression
Frequent anxiety and worry (e.g., Generalized Anxiety Disorder)
Anxiety in social situations (e.g., Social Anxiety Disorder)
Frequent panic attacks or Panic Disorder
Attention Deficit/Hyperactivity Disorder
Posttraumatic Stress Disorder
Bipolar Disorder
Tourette's Syndrome/Motor or Vocal Tic Disorder
Autism
Behavioral Disorder (Oppositional Defiant Disorder or Disruptive Behavioral Disorder)
Selective Mutism
Learning Disorder(s)
Intellectual/Cognitive Disabilities
Developmental Disorder(s) or Developmental Delays
Obsessive Compulsive Disorder
Eating Disorder or Nutritional Concerns (AFRID, Anorexia Nervosa, Bulimia Nervosa, etc)
Loss/Grief
Sleep Disorder or Significant Sleep Problems
Problems with peer interactions (e.g., bullying, rejection, etc.)
Head or brain injury (seizures, concussion, head trauma, etc.)
Other (not listed)
Does your loved one have any current medical conditions impacting their mental health?
Does your loved one engage in any of the following?
Rows
Yes
No
Aggression towards self or non-suicidal self-injury
Suicidal ideation or suicidal behaviors
Aggression towards others
Abuse or misuse of illicit substances, over-the-counter medications or prescribed medications.
School avoidance/refusal
Skin picking or hair pulling
Enuresis/encopresis (bed-wetting/toileting difficulties)
Breaking laws, leading to arrest or other difficulties
Has your loved one ever received treatment from a mental health provider? If yes, please provide some detail.
Has your loved one ever participated in a higher level of care for psychological treatment (e.g., inpatient hospitalization, residential treatment, IOP, PHP)? Please check all that apply.
Intensive Outpatient Program (IOP)
Partial Hospitalization Program (PHP)
Residential Program
Inpatient admission/hospitalization
Boarding school
Wilderness program
Other
Has your loved one been identified as a child in need of special education or do they have an IEP? If yes, please provide some detail.
My loved one is either aware I am completing this form on their behalf, or I am confident they will be okay with it when I tell them.
Yes
No
Unsure
Submit
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