Child/Adolescent Waitlist

Welcome to COAC! Please complete this confidential form to the best of your ability. We will use this information to ensure we are the best fit for your loved one's needs.

After submitting the form, we will follow up with you by phone by the end of the next business day from our main office number: 614-706-0504.
Interested in treatment at COAC? Please select your highest priority for treatment to get started.*
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
We accept most, but not all, Medical Mutual plans. We will need to ask some additional questions to help you determine if we are in-network with your plan. First, was your Medical Mutual insurance plan purchased on the Marketplace, or provided by an employer?*

Purchased on the marketplaceProvided by the policy holder's employer
Is the policy holder of the Medical Mutual insurance plan an employee of the state of Ohio?*

Yes, the policy holder is a state employeeNo, the policy holder works for a private company, a city municipality, county, or school district
Marketplace plans

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Unfortunately, we do not accept most Medical Mutual (HMO) plans offered on the Marketplace. Please check with your insurance provider to verify that we are in-network with your specific plan before completing this form. If we are not in-network, please select "I am out of network, but would like to self-pay" before continuing with the form.

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Good news! At this point, it appears we are likely an in-network provider. We always encourage prospective patients to confirm with their insurance company before starting treatment. We will also double-check your insurance card if you decide to upload a copy of it.

Please continue completing the form...
State Employee Plans

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Unfortunately, we are very likely out-of-network with your plan. Employees of the State of Ohio have Medical Mutual insurance for medical coverage, but not behavioral health. If you are a state employee, you almost certainly have Optum insurance for behvavioral health (not Medical Mutual). Please call your insurance carrier or HR department to confirm.

State employees can also verify this by calling the number on the back of their insurance card for Bevavioral Health. If the number goes to Optum Insurance, we are not in-network.

If you would like to still recieve services from us, please change your answer to "I am out of network, but would like to like to self-pay."

*Optum is owned by UnitedHealthcare. If you decide to look for other providers who accept your insurance, consider adding UnitedHealthcare (UHC) to your search, as the majority of providers who are in-network with UHC are also in-network with Optum (even if they don't list it on their websites). This information is for your convenience, and may not be accurate in all circumstances.

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

Licensed Clinical Therapist (45 Min: $195; 60 Min: $285; Intake $325)
Please select your preference:*

Telehealth onlyPrefer TelehealthOpen to eitherPrefer in-personIn-person only
I am out of network, and would like to receive documentation (i.e., Superbills) to file my own insurance claims.*

YesNo
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
Name of person completing this form*

First NameLast Name
Relationship to the patient*
Phone number of the person completing this form*
Please enter a valid phone number.
Email of the person completing this form*
example@example.com
Name of the patient:*

First NameLast Name
Patient's birth date:*

MonthDayYear
Date
The patient has a custody agreement/order in effect or is expected to have a custody agreement/order in effect in the next 12 months.

Yes, there is or will be a custody agreement in effectNo, there are no custody agreements in effect
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. *

0/250
My loved one experiences repetitive and unwanted thoughts, mental images, and/or impulses that cause distress or anxiety (i.e., obsessions).*

Not a problemMildModerateSevereUnknown
My loved one often feels compelled to perform repetitive behaviors or mental acts to reduce anxiety, or to stop something bad from happening (i.e., compulsions).*

Not a problemMildModerateSevereUnknown
My loved one has been diagnosed with pediatric acute-onset neuropsychiatric syndrome (PANS) or pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)

YesNoUnkown
My loved one experiences excessive, uncontrollable worry about a variety of everyday topics much of the time.*

Not a problemMildModerateSevereUnknown
My loved one frequently experience intense anxiety in social situations, such as meeting new people, or participating in group activities. Social anxiety interferes with their life.*

Not a problemMildModerateSevereUnknown
My loved one experiences intense fear or anxiety when exposed to particular objects, situations, or activities (e.g., spiders, heights, flying, animals/insects, needles) that interferes with their life (i.e., phobia).*

Not a problemMildModerateSevereUnknown
My loved one frequently worries about panic (anxiety) attacks, and/or often avoids situations specifically so they do not have a panic attack.*

Not a problemMildModerateSevereUnknown
My loved one experiences excessive separation anxiety.*

Not a problemMildModerateSevereUnknown
My loved one frequently picks their skin or pulls out their hair and finds it very hard to stop.*

Not a problemMildModerateSevereUnknown
My loved one is highly preoccupied with perceived flaws in their appearance that are insignificant or hardly noticeable to others.*

Not a problemMildModerateSevereUnknown
My loved one experiences sudden movements (e.g., tics) or make sounds that are hard for them to control.*

Not a problemMildModerateSevereUnknown
For at least the past two weeks, my loved one has felt sad/down or much less interested in things they typically enjoy.*

Not a problemMildModerateSevereUnknown
My loved one has been previously diagnosed with bipolar disorder.*

YesNoUnknown
My loved one has experienced or witnessed a traumatic event that currently causes them distress and interferes with their daily life.*

Not a problemMildModerateSevereUnknown
My loved one has persistent problems related to food intake and/or body weight (e.g., fear of gaining weight, food restriction, binging/purging, eating non-food items).*

Not a problemMildModerateSevereUnknown
My loved one has been diagnosed with autism spectrum disorder, or I strongly believe they have autism.*

YesNoUnknown
My loved one has been diagnosed with ADHD, or I strongly suspect they have ADHD.*

YesNoUnknown
Has your loved one ever participated in a higher level of care for psychological treatment (e.g., inpatient hospitalization, residential treatment, IOP, PHP)?*

Intensive outpatient program (IOP)Partial hospitalization program (PHP)Residential programInpatient admission/hospitalizaitonBoarding schoolWilderness programNone
My loved one is receiving special accommodations at school due to mental health symptoms (e.g., IEP, 504).*

YesNoUnknownOther
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.*

YesNoUnsure
Patient's Age
Today's Date

MonthDayYear
Date
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