Psychworks Wait List Request

Please fill out the following information so someone can reach you when an appointment is available at the practice.

If you are a parent seeking therapy for your underage child, please complete this form with your child's personal information, but provide the parent/guardian's contact information.

Completing this form indicates your desire to be placed on a waitlist and in no way starts or guarantees a therapeutic relationship.

Name of intended client:

First NameLast Name

Date of Birth:

Age

Gender:

Pronouns:

Ethnicity:

Local Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Format: (000) 000-0000.

May we call and leave a message?

Email:

example@example.com

May we contact you via email regarding appointments?

Which way do you prefer to be contacted?

Is the intended client a minor (under the age of 18)

Name of Parent/Guardian:

First NameLast Name

Relationship to the minor

Have you ever previously been involved with outpatient mental health treatment (i.e. group therapy or individual?)

Briefly describe your previous mental health experience, who you saw, and the nature of treatment.

Will you be using Health Insurance or Self Pay?

Please identify the name of your health insurance company.

Examples: Anthem, Cigna, Optum, CareSource, etc.

Please provide your insurance card member ID number.

Please briefly describe why you are looking for therapy at this time.

I am seeking:

Choose a type of service

Name of Partner

First NameLast Name

Email of your partner:

example@example.com

I am considering

Other

I prefer:

I would like to work with:

I would like to work with

Psychworks Clinic is open for virtual appointments Monday through Friday 10-6pm, and some limited Saturday appointments. All appointments are Eastern standard time.

Please try to provide us with as many times when you could be available to be seen. More available times could speed up the process for you to be seen sooner.

Please provide a range of dates and times when you might be available for virtual sessions.

Rows	10am	11am	12pm	1pm	2pm	3pm	4pm	5pm	6pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please provide a range of dates and times when you might be available for in-person sessions in Cincinnati, OH

Rows	10 am	11 am	12 pm	1 pm	2 pm	3pm	4 pm	5 pm	6pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Please provide a range of dates and times when you might be available for in-person sessions with Dr. Ritch Hall in Oxford, OH.

Rows	10am	11am	12pm	1pm	2pm	3pm	4pm	5pm	6pm
Thursday
Friday

Please provide a range of dates and times when you might be available for in-person sessions with Nancy Roane LISW in Oxford, OH.

Rows	5pm	6pm
Monday

Choose a range of available times for Nancy Roane LISW in Oxford, OH

Rows	9am	10am	11am	12pm
Sunday

How did you hear about Psychworks Clinic?

Is there anything else you feel we should know?

Please check to indicate understanding of the following:

Your privacy is important to us. We will never share your personal information.

Psychworks Clinic Wait List Request