Provider Referrals

Provider referral form

Thank you for your trust in Columbus OCD and Anxiety Clinic. To refer a patient to our clinic, please complete the following HIPAA-complaint form. All information is secure and confidential.
We are paneled with most plans for the following insurance companies:

Cigna

Aetna

Medical Mutual

Ohio Healthy

Self-pay rates:

Intake ranges from $350-$375 depending on provider

45-min therapy session ranges from $195 (most providers) to $285

Average Wait Time:

We are able to place most patients with a clinician within 6 weeks. We can sometimes make exceptions for patients with urgent needs.
Referring provider's name*

First NameLast Name
Referring provider's organization*
Referring provider's phone number*
Please enter a valid phone number.
Referring provider's fax number
Please enter a valid phone number.
Patient's name*

First NameLast Name
Patient's DOB*

MonthDayYear
Date
Patient's phone number*
Please enter a valid phone number.
Primary target for treatment:

OCDAnxiety-related disorderSkin picking/Hair pullingPTSDMood-related disorderOther
Is this patient stepping down from a higher level of care?

PHP/IOPResidentialHospitalizationNoneOther
Does the patient need to be evaluated on an urgent basis?

YesNoOther
Would you like us to follow-up with you after we have evaluated this patient?

YesNo
Are you referring to a specific provider(s) at COAC?

YesNo
Please indicate to whom you are referring the patient? We do our best to accommodate requests for specific providers.

Dr. Matthew Free (adults)Dr. Justin Braun (adults)Dr. Lawrence Needleman (adults)Keri Willard, LPCC (ages 8 and up)Chris Palcsak, LISW (adults)Michael Bayda, LISW (adults)Paul Kitzmiller, LPCC (ages 16 and up)Lisa Kapp, LPCC (ages 16 and up)Rachel Michael (ages 12-18)
Is anything you else you would like us to know about this patient?
If you need to forward us any relevant records or documents, you may upload them here to our HIPAA-compliant drive.

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Provider referral form