First Name
*
Last Name
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Phone
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Email
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Address
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City
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State
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Postal code
*
How do you prefer we contact you? (check all that apply)
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Text
Email
Phone Call
How did you hear about our practice?
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Google
Psychology Today
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Provide the name of the person or place that told you about us.
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Are you the individual who is legally allowed to make medical decisions for your minor child?
*
Please Select One
Yes
No
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Is there an active custody case regarding your child?
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Yes
No
At this time, we are unable to provide services when a custody case is pending or ongoing. Would you like to proceed with the intake questions and have our staff reach out to you with possible resources?
Yes
No
Name of your insurance company:
*
Please select one from the dropdown
Aetna
Cigna
First Health
Humana (except Medicare/Medicaid plans)
Medical Mutual
Ohio Healthy/ Optima
Ohio Health Choice
OSU PrimeCare
OSU Student
Anthem/BCBS (self-pay)
United Health Care/Optum/UMR (self-pay)
Medicaid (self-pay)
Medicare (self-pay)
Tri-Care (self-pay)
Self-pay (not using insurance)
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Please upload the front and back of your insurance card
Policy Holder Name
*
Policy Holder Date of Birth
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Policy Holder's Employer
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Relationship to Policy Holder
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Self
Spouse/Partner
Child
Other
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If you are not the primary policy holder, will we be billing you or the primary policy holder for any co-pays/deductibles/or session costs?
Please select one
You will be billing me
You will be billing the primary policy holder
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A credit card is required to be presented at the time of service. Will you be using your own credit card, or someone else's credit card?
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My own credit card
Someone else's credit card
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If you are using someone else's card, please provide their name, email address, and their relationship to you, as we will require an authorization and a release of information for billing purposes.
*
What type of Medicaid product are you covered under?
Please select one
Caresource
Molina
Aetna Better Health
Buckeye Health
United Health Care Community Plan
Other
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Your insurance will be out-of-network. We are not contracted with any Medicaid or Medicare products. If you choose to see one of our licensed independent therapists, you will be unable to submit to your insurance for reimbursement. We offer lower-cost options for those with Medicaid/Medicare/Tricare or uninsured. Our Psychology Residents are supervised by our Psychologists on staff to provide expert care while being able to receive care at a more affordable rate. Our regular 55 minute therapy sessions will cost $25-$40 if you see one of our Psychology residents who are currently in a doctoral program seeking their clinical psychology degree. We are unable to agree to single case agreements. If you are interested, we can provide more information. Would you like to continue with requesting an appointment?
Please select one
Yes
No
Need more information, please contact me
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Your insurance will be out-of-network. We will provide Superbills (receipt) for you to submit to your insurance company. You are responsible for the full rate of our services on day of service, and some insurances will reimburse for out-of-network services. We are happy to provide superbills and help you navigate how to initiate submission for out-of-network reimbursement if you choose to schedule with us. We offer lower-cost options for those with commercial insurance who are out-of-network if you see one of our supervised therapists if our regular self-pay rates are not feasible. These supervised therapists are either post-degree who are being supervised by one of our experts to obtain hours for licensure, or currently in a doctoral program seeking their clinical psychology degree. The rates for 55 min therapy sessions range from $75-$175 for out of pocket expenses. We are unable to agree to single case agreements. If you are interested, we can provide more information. Would you like to continue with requesting an appointment?
Please select one
Yes
No
Need more information, please contact me
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Child's Full Name
*
Child's Date of Birth
*
Child's Gender
*
Female
Male
Non-Binary
Prefer not to say
Other
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Child's Email Address
Should you wish to schedule, do you understand that you will need to create an email address for your minor child?
*
Yes
No
My child is under 14 and does not need to sign consents.
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Do you struggle with any eating, weight, or body image concerns?
*
Please select one
Yes
Maybe
No
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Are you trying to control your weight or intentionally lose weight in any way?
*
Please select one
Yes
Maybe
No
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In what ways do you try to control your weight with food? Select all that apply.
I am dieting or trying to eat less.
I skip meals
I count calories
I avoid certain foods or food groups
If you answered yes to any of the above, how often does this occur?
Please select one
Multiple times per day
Daily
Several times a week
Once a week
Less than once a week
Monthly
Other
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On a typical day if you are trying to control your weight or eat less, what do you eat?
*
Do you feel uncomfortable with/avoid foods due to taste, texture, or presentation or have a fear of vomiting or choking?
*
Please select one
Yes
No
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I avoid foods because:
*
I worry about choking or vomiting when eating
I have a lack of interest in food
I don't like physical sensations (texture) of certain foods
Other
On a typical day, what do you eat?
Do you ever feel out of control when eating?
*
Please select one
Yes
No
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In thinking about the last two to three weeks, on average how often has this occurred?
Please select one
Multiple times per day
Daily
Several times a week
Once a week
Less than once a week
Monthly
Other
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Are any of the below statements true?
*
I eat more than others think would be a normal amount of food.
I eat more quickly when I feel out of control.
I eat in secret or hide evidence of eaten food.
I eat in response to stress.
None of these statements are true.
Do you ever struggle with intentionally vomiting after eating?
*
Please select one
Yes
No
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How often have you vomited in the last month?
*
None
Once a week
2-3x per week
4-5 times per week
Daily
Multiple times per day
Do you take laxatives and/or diuretics to lose weight?
*
Please select one
Yes
No
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How often have you taken laxatives or diuretics in the last month?
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None
Once a week
2-3x per week
4-5x per week
Daily
Multiple times per day
Are you currently exercising?
*
Please select one
Yes
No
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How often do you exercise?
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Multiple times a day
Daily
Several times a week
Once a week
Less than once a week
Monthly
Other
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Which of the following statements are true regarding exercise?
I exercise to lose weight.
I feel compelled to exercise.
I exercise to compensate for what I've eaten.
My friends or family think I exercise too much.
I exercise for stress relief/to improve mental health.
None of the above.
Height in inches
*
Weight in pounds
*
How much has your weight changed in the past 3 months? (Please indicate whether it is an overall weight loss of gain, if applicable)
*
Have you experienced any of the following in the last month?
*
Dizziness
Fainting
Chest Pain
Frequent Heart Palpitations/Fluttering
Blood in Vomit
Low Blood Sugar
Current or History of Abnormal EKG
None
If you indicated any physical symptoms in the last month, please describe them in more detail here (if you have an associated diagnosis related to the symptoms, please share here).
Pediatrician/PCP Name
*
Pediatrician/PCP Phone
*
Pediatrician/PCP Office Name
*
Does your doctor have any concerns about your health?
*
Please select one
Yes
No
My doctor does not know I have an eating disorder
My doctor and I have not discussed any medical concerns
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If your doctor has expressed concerns about our health, please list the concerns they have shared with you.
If you currently see a dietician/nutritionist, what is their name and telephone number?
Do you struggle with any of the following mental health concerns?
*
Depressed/low mood
Anxiety/worry
Trauma/PTSD
OCD
Distress over chronic health concerns (diabetes, POTS, PCOS, ect)
Insomnia/sleep concerns
ADHD
Other
If you struggle with any of the above, what would be helpful for us to know?
Do you struggle with thoughts to end your life or hurt yourself in some way?
*
Please select one
Yes, I have wished I were dead or wished I could go to sleep and not wake up.
Yes, I have thoughts of killing myself.
Yes, both of the above.
No
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How frequently do you struggle with these thoughts?
*
Please select one
Always
Often
Sometimes
Rarely
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Have you ever acted on these thoughts?
*
Please select one
Yes
No
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When was the last time you acted on these thoughts?
*
Have you every been hospitalized because of any self-harming behaviors?
*
Please select one
Yes
No
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If so, when and where were you hospitalized?
*
Are you on any medications for mental health concerns?
*
Please select one
Yes
No
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If yes. what medications are you prescribed and who prescribes these medication (please list the physician name and telephone number)
Are you currently seeing a therapist for any mental health concerns? If so please provide their name and phone number.
Which days of the week are you available for appointments?
*
Monday
Tuesday
Wednesday
Thursday
Friday
What times of the day are you available for appointments? Please note that our after school and evening appointments are limited and highly requested, therefore more flexibility in your availability will help us be able to schedule you as quickly as possible. We are happy to provide school and work excuses if you need one.
*
Early Morning: 8:00AM - 10:00AM
Late Morning: 10:00AM - 12:00PM
Afternoon: 12:00PM - 3:00PM
Late Afternoon 3:00PM - 5:00PM
Early Evening: 5:00PM - 7:00PM (please note, you may be placed on a waitlist if this is the only time requested.)
Do you foresee any changes to your availability that might make a difference in your ability to schedule appointments? (changing jobs, starting school, moving out of state, changing insurance, etc.)
*
Please select one
Yes
No
Maybe
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If you foresee any changes, what might they be and when might they occur?
Do you prefer virtual or in-person appointments?
*
Please select one
Virtual
In-person
Either
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Do you have a specific clinician in mind? (please note certain clinicians may have a short wait list)
*
Please select one
Yes
No, I'm interested in scheduling with the first available clinician
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If yes, which child and adolescent therapist(s) are you interested in scheduling with? (If they are not available, we may suggest another therapist based on your answers).
*
Chelsea Tobias, LISW-S (6yo+)
Jennifer Barney, PhD (6yo+)
Megan Thaler, LISW (6yo+)
Erica Temes, PhD (6yo+) (supervised by Dr. Carolyn Fisher)
Rosha Hebsur, PsyD (12yo+)
Kate Hibbard-Gibbons, PhD (13yo+)
Jaida Green, LISW (13yo+)
Is there anything else that you are struggling with you that you would like us to know?
If you are agreeable, which sessions would you be open to having a resident observe?
*
Initial intake only
Follow-up appointments only
Any appointments
I have some questions about what observation entails, and would like someone to reach out to me
I do not wish to have a resident observe any of my sessions
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