Pre-Screen Form

Interested in treatment at COAC? Please select your highest priority for treatment to get started.*
Welcome to COAC! Please complete this confidential form to provide important information and to make sure that we are the best fit for your needs.
How did you hear about us?*
Please explain "Other"
Please name the provider that told you about us.
Please select your insurance plan, or if you are out of network*

I am out of network, but would like to self-payAetnaAetna AdvantageCignaHumanaHumana MedicareMedical MutualOhioHealthyDevoted Health
Please note the following self-pay fees, and select the option that works best for you:*

Psychologist (45 Min: $220; 60 Min: $285)Licensed Clinical Therapist (45 Min: $185; 60 Min: $265)First Available
Please select your preference:*

Telehealth onlyPrefer TelehealthOpen to eitherPrefer in-personIn-person only
If you will be seeking telehealth services while physically in any other state than Ohio, please list any and all states that may apply (excluding brief trips, vacations, etc.)*
I am out of network, and would like to receive documentation (i.e., Superbills) to file my own insurance claims.*

YesNo
Please provide the best times to reach you over the next two business days.*
Do we have permission to contact you after 8 PM?*

YesNo
Name*

First NameLast Name
Birth Date:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please briefly describe the primary reason you are seeking treatment:*

0/40
My upbringing or family circumstances growing up has affected me ________.*
I experience repetitive and unwanted thoughts, mental images, or impulses that cause distress or anxiety.*

Not a problemMildModerateSevere
I feel compelled to perform repetitive behaviors or mental acts to reduce anxiety, or to stop something bad from happening.*

Not a problemMildModerateSevere
I experience excessive, uncontrollable worry much of the time.*

Not a problemMildModerateSevere
I frequently experience intense anxiety in social situations, such as meeting new people, speaking in public, or participating in group activities, that interferes with my daily life.*

Not a problemMildModerateSevere
I experience intense fear or anxiety when exposed to particular objects, situations, or activities (e.g., spiders, heights, flying, animals/insects, needles) that interferes with my life.*

Not a problemMildModerateSevere
I have a fear of having panic or anxiety attacks, and avoid potentially triggering situations.*

Not a problemMildModerateSevere
I experience excessive anxiety in situations where it may be difficult to escape or may be embarrassing to have distressing symptoms (e.g., panic attack, vomiting, diarrhea).*

Not a problemMildModerateSevere
I worry a lot about developing a serious illness (e.g., cancer) or about certain physical symptoms that I am experiencing.*

Not a problemMildModerateSevere
I pick my skin or pull out my hair and find it hard to stop.*

Not a problemMildModerateSevere
I am preoccupied with perceived flaws in my appearance that are insignificant or not noticeable to others.*

Not a problemMildModerateSevere
I experience sudden movements (e.g., tics) or make sounds that are hard to control.*

Not a problemMildModerateSevere
For the past two weeks, I have felt sad/down or am much less interested in things I typically enjoy more often than not.*

Not a problemMildModerateSevere
I have been diagnosed with bipolar disorder, or I think I might have had a manic episode.*

YesNo
I have experienced or witnessed a traumatic event that continues to cause me distress or interfere with my daily life.*

Not a problemMildModerateSevere
I have persistent problems related to food intake and/or body weight that interferes with my life (e.g., fear of gaining weight, food restriction, binging/purging, or weigh less than others think I should).*

Not a problemMildModerateSevere
In the past 6 months, I have been hospitalized for a psychological issue or problem (e.g., inpatient hospitalization, IOP, PHP)*

YesNo
In the past year, I have regularly (e.g., daily/weekly) used illegal drugs or prescription medications in ways that were not prescribed.*

Not a problemMildModerateSevere
My drug habits cause problems, interfere with my life, or cause concern for my family/friends.*

Not a problemMildModerateSevere
I consume approximately _____ number of alcoholic beverages per week.*
My drinking habits cause problems, interfere with my life, or cause concern for my family/friends.*

Not a problemMildModerateSevere
With the right kind of treatment, I think I could make progress with improving my mental health.*

YesNo
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