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

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?

Is the policy holder of the Medical Mutual insurance plan an employee of the state of Ohio?

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:

Please select your preference:

I am out of network, and would like to receive documentation (i.e., Superbills) to file my own insurance claims.

Please provide the best times to reach you over the next two business days.

Do we have permission to contact you after 8 PM?

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.Format: (000) 000-0000.

Email of the person completing this form

example@example.com

Name of the patient:

First NameLast Name

Patient's birth date:

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.

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.

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

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).

My loved one has been diagnosed with pediatric acute-onset neuropsychiatric syndrome (PANS) or pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)

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

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.

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).

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

My loved one experiences excessive separation anxiety.

My loved one frequently picks their skin or pulls out their hair and finds it very hard to stop.

My loved one is highly preoccupied with perceived flaws in their appearance that are insignificant or hardly noticeable to others.

My loved one experiences sudden movements (e.g., tics) or make sounds that are hard for them to control.

For at least the past two weeks, my loved one has felt sad/down or much less interested in things they typically enjoy.

My loved one has been previously diagnosed with bipolar disorder.

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

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).

My loved one has been diagnosed with autism spectrum disorder, or I strongly believe they have autism.

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

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

My loved one is receiving special accommodations at school due to mental health symptoms (e.g., IEP, 504).

Other

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.

Patient's Age

Today's Date

Date