Primary Location

6294 Gender Rd

Canal Winchester, OH 43110 United States

614-321-9298

Forms and Agreements

Family

If you're a new client, please complete the following forms and bring them to your first therapy session.  

Note: During Covid-19 all sessions are conducted virtually for the safety of our community.  During this time all paperwork is to be submitted by fax (614-437-4075) or emailed to ([email protected]) within 48 hours prior to your scheduled appointment. We do not accept photos of paperwork at this time.  Please note that we are willing to meet face to face to collect paperwork if you aren't comfortable with sending documents electronically. Emails we send are encrypted. Emails sent to us are not unless you have encrypted them. 

Virtual Platforms: FaceTime (During Covid only), Google Duo (During Covid only), Zoom, Skype (During Covid only), Doxy.me and Therapy Notes. 

Documents to bring/provide: Please bring/present your insurance card and a government issued photo identification.  The insurance information needs to be provided 48 hours prior to your scheduled appointment so that we may verify coverage details. 

Appointment Time: Your appointment will start within (after) 15 minutes of your appointment time.  This is a grace period for therapist in case he/or she runs over in the previous session or needs an extra moment to prepare for your session. We will initiate the call. Thanks for your patience. We won’t forget about you.

◆ Client Information Form

◆ Client Consent Form

◆ Client Intake Form

◆ HIPAA Form

◆ Permission To Treat A Minor Form

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

◆ Authorization to Release Information Form Note: To download Adobe Acrobat Reader for free, click here 


Contact Us

Location

Availability

Primary

Monday:

Flexible Appointment Times Available. Contact Us for More Information

Tuesday:

Flexible Appointment Times Available. Contact Us for More Information

Wednesday:

Flexible Appointment Times Available. Contact Us for More Information

Thursday:

Flexible Appointment Times Available. Contact Us for More Information

Friday:

Flexible Appointment Times Available. Contact Us for More Information

Saturday:

Flexible Appointment Times Available. Contact Us for More Information

Sunday:

Flexible Appointment Times Available. Contact Us for More Information