Patient Forms

In order to become a new patient you will need to fill out & submit Packets #1 and #2.

You will also need to email us a copy of your photo ID & front/back of your insurance card to newpatient@centralohiocounseling.com.

Once we've received all of your information we will call you to set up your first appointment.

Packet #1.pdf

Packet #2.pdf

Records Release / HIPAA.pdf

Telemental Consent.pdf

Note: These files are in PDF format. If you do not have Adobe® Reader® on your computer, you can download it for free by clicking here.