An Association of Independent PractitionersPhone/Text/Fax: 614-360-2600

To our clients: We are glad you’re here and we look forward to the opportunity to help you feel better! Below are some of our policies to help familiarize you with our practice.

Location: First, confirm that you are in the correct location. Each staff person works in one location only.

Appointments: Psychotherapy appointments are scheduled for around 50 minutes. Brief and extended appointments are offered when necessary. If you find it necessary to cancel a scheduled appointment, we request 48 hours-notice in advance (unless due to circumstances beyond your control). We typically have a wait list and if you give us enough time, we can offer that slot to someone else.

Cancellations: We understand the life happens and for this reason, we will give you one free late cancel/no show per calendar year. If you need to cancel or change an appointment, be sure to give us at least 48 hour notice otherwise you will be charged the full fee for the appointment time reserved. Insurance companies will not pay this fee, so we urge you to give proper notice when canceling, for your benefit and ours. If you are unable to give 48-hour notice, call us as soon as possible. If we are able to fill your appointment on short notice, we may be able to waive the fee.

Location Address Staff exclusively at this location:

Dublin 6631 Commerce Parkway, Suite R Dublin OH 43017

-Kim Boggs-Asia Place -Christine Rager-Mikel Sinnott-Melaney Thurman-Kate Vessels

New Albany 5071 Forest Drive, Suite B (front) New Albany OH 43054

-Karen Bretz-Laura Davis-Jaclyn Groh-Sarah Vorhis-Allie Whittington

Westerville 635 Park Meadow Road, Suite 101 Westerville OH 43081

-Amy Bush-Sarah Grim-Erika Stein

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Billing: Payment is expected at the time of service for your portion of the co-pay, deductible, or payment in full if you are not using insurance for services provided. Your prompt payment allows us to keep our fees to you as low as possible. We bill your insurance company as a courtesy service to you, but it is your responsibility to make sure that your bill is paid in full to us. If you anticipate any problems in paying your bill, you should discuss this with us as soon as possible to make a payment plan. Please note that there is a $45 service charge for all returned checks. Also, balances older than 30 days may be subject to a l.5%/month (18%/year) finance charge, and in cases of payment default, you will be charged for any collection fees we may incur, with a minimum of an additional $25.00 fee. At the bottom of this form is a credit card authorization form. No personal checks or cash will be accepted after August 1, 2018.

Email: Email is not a secure form of communication. You can use email to contact your therapist if that is something your therapist feels comfortable with; however, by choosing to do so you recognize the risk of your email or ours being compromised. The safest way to communicate is through the patient portal or calling the main number.

Insurance: Please note that it is your responsibility to know your benefits, and that it is your responsibility to pay us. We generally try to verify your insurance before you come in, but occasionally insurance companies give us erroneous information. When this happens, you agree that you are still ultimately responsible for payment in full to us. While we will do all that we can to assist you in filing your claims and seeing that proper payment is made, you are ultimately responsible for knowing your policy and for full payment of your bill. We strongly suggest that you verify your insurance benefits and know if you have any maximum eligible payments per therapy session or per year. Disputes with your insurance company are between you and them.

Emergencies and After Hours: If you or someone you love is experiencing a crisis, call 911 or go to the emergency room or call OSU Harding at 293-9600. In Franklin County you can also call Netcare Access at 276-2273; in Delaware County you can call 684-2324. Emergency messages should not be left on the voice mail system or emailed. If you are feeling suicidal, or that you might hurt someone else, do not hesitate to use one of the emergency resources immediately!

Confidentiality: Everything that takes place in psychotherapy is confidential, and may not be released without your express written permission. There are two exceptions to this; if you become actively suicidal or are thinking of hurting someone else, and if you are involved in child or elder abuse. We are legally bound to protect you and the other parties, and confidentiality may have to be broken. If you have insurance that uses managed care, treatment information must be released to them in order for your insurance to pay for services rendered to you. We may ask you to sign a release of information form so that we may communicate with your other doctors, previous therapists, or family members. You have the right to refuse to sign these forms if you so choose. Also, confidentiality for minors as well as for couples and families should be discussed with your therapist. Finally, if we see you in public or on social media, we are prohibited from acknowledging you as doing so could be a violation of your confidentiality.

Ethics and professional standards: As mental health providers licensed by the State of Ohio, we agree to abide by and uphold the most responsible ethical and professional standards possible. We accept responsibility for the consequences of our acts and make every effort to protect the welfare of our clients and to ensure that our services are used appropriately.

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If you are unhappy with your services here, it is especially important that you try your best to communicate with us the sources of your dissatisfaction. You may do this in writing if you feel uncomfortable speaking to your therapist, the office manager (Courtney), or Dr. Bretz. If we do not reach an agreeable solution and you need help finding additional or alternate assistance, we will do our best to help you locate a more suitable referral or therapy resource. Our ethics prevent us from seeing a client who is seeing another individual therapist except in extenuating circumstances, should you wish to work with another therapist for services, it is important that you indicate your desire to make a change.

Release of Liability: If you fail to show for an appointment, we will try to contact you during that appt. time at the number you have provided. If we do not hear from you within one week of the missed appointment, you have released us of all liability for your psychological counseling/care. Also, if you cancel an appointment without rescheduling, you release us from liability for your psychological care/counseling. You are welcome to reschedule at any time, provided any past balances, including no show fees, are paid. Of course there are extenuating circumstances, such as an extended vacation, family emergency, unforeseen business trip, etc. In such cases, please contact us as soon as possible to keep us informed.

Forensic, Disability, and Legal Issues: We do not provide reports or recommendations for custody evaluations, a guardian ad litem, disability or FMLA applications for clients because the therapeutic relationship will be compromised if there is another agenda. In other words, we cannot be therapists and forensic evaluators at the same time.

I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. If I do not pay this balance within 30 days of being billed, I understand that a 1.5%/ month (18%/year) interest charge may be added to my account until the balance is paid in full. If I do not pay this balance or arrange a payment plan, I understand that I may be turned over to a collection agency and I will be billed for any subsequent collection charges, including a minimum charge of $25.00. I certify this information is true and correct to the best of my knowledge, and I will notify you of any changes in my health insurance or the above information as soon as possible. I agree to abide by the cancellation policy as well. Your signature below indicates that you have read policies and procedures detailed above and agree to abide by its terms during our professional relationship.

Patient or Parent of Patient Signature: _________________________________________________

I have read and/or have received a copy of the HIPAA Notice Form.

Patient or Parent of Patient Signature: _________________________________________________

I understand that my mental health provider, as an independent contractor, is solely legally responsible for my treatment and care.

Patient or Parent of Patient Signature: _________________________________________________

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OHIO NOTICE FORM CONTRACT

I have read and had an opportunity to ask questions about the Notice Form on the Policies and Practices to Protect the Privacy of My Health Information.

My signature below acknowledges my understanding and agreement with this document including that:

1. I give my consent to Columbus Behavioral Health, LLC to use and disclose my protected health information (PHI) for treatment, payment, and health care operations purposes.

2. I may sign an Authorization Form to release my records to others as desired.

3. My PHI may be released without authorization in cases of suspected abuse or threat to safety, by Court order, or Worker’s Compensation claim.

Patient or Parent of Patient Signature: _________________________________________________

Copies of all documents are available on our website: www.columbusbehavioralhealth.com

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NEW PATIENT PAPERWORK

Name of patient: ________________________________________ Date : _________ Pronouns: ______

DOB: ___________ Age: ___________ Gender: ____________ Relationship Status:_________________

Address: _____________________________________________ City & Zip: _______________________

Primary Phone: _________________________________________ Ok to call? Y N Text? Y N

Secondary Phone: ______________________________________ Ok to call? Y N Emergency only

Email: ________________________________________________ Ok to email? Y N Emergency only

Emergency Contact: _______________________________ Emergency Phone: ___________________

Online username: _________________________________ Password:___________________________

Insurance Information

Insured’s Name: ______________________________ Relationship: _________ DOB: ________________

Primary Insurance: ________________________________ Phone: _______________________________

Group No: _______________________ ID: ___________________ Effective Date: __________________

Is it ok to bill the credit card on file for your co-pays? Y N

Your primary care physician (PCP): ________________________________________________________

_____ I authorize CBH to release/exchange treatment information with my family physician and health plan’s utilization reviewers in order to facilitate my treatment at CBH.

____I understand that I am financially responsible for any balance or copay covered by my insurance.

___________________________________________ ________________ Signature of Patient, Parent or Guardian Date

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PLEASE CHECK THE ITEMS WHICH ARE CURRENTLY A CONCERN:

DAILY FUNCTIONING

Why did you decide to call for services at this time? _____________________________________________________________________________________ _____________________________________________________________________________________

_______ Academic Problems _______ GLBTQ+

_______ Addictive Behaviors _______ Isolation/Loneliness

_______ Anxiety, fears, worries _______ Legal Issues

_______ Anger issues _______ Military Combat experiences

_______ Alcohol use _______ Mood variability

_______ Bipolar Disorder _______ OCD

_______ Breakup/Divorce _______ Pain/Chronic Medical Illness

_______ Career Uncertainty _______ Parental divorce

_______ Childhood abuse _______ Parental drug or alcohol use

_______ Concentration Problems _______ Physical Problems

_______ Decision about academic future _______ Recent move or life transition

_______ Depression _______ Relationship Issues with parents

Domestic Violence _______ Romantic Relationship Issues

_______ Drug use _______ Self harm

_______ Eating Disorders _______ Sexuality issues

_______ Emotional abuse in past or present relationship

_______ Self esteem problems

_______ Experiencing Discrimination _______ Sibling Relationship Issues

Family of origin issues _______ Sleep problems

_______ Friendship/social problems _______ Suicidal thinking

_______ Gender issues _______ Traumatic experiences

_______ Getting in trouble at work/home _______ Weight management

_______ Other: ___________________ _______ Work stress

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Who in your life is concerned about you right now? _____________________________________________________________________________________ _____________________________________________________________________________________

What specific symptoms (additional to the ones notated above) are you experiencing? _____________________________________________________________________________________ _____________________________________________________________________________________

What is your current job title (if applicable)? _____________________________________________________________________________________ What is your highest level of education? _____________________________________________________________________________________ What is your current living situation? _____________________________________________________________________________________ What is your religious affiliation? _____________________________________________________________________________________ Who are the 3 people closest to you currently? _____________________________________________________________________________________ How is your sleep? (e.g, how well are you sleeping, nightmares, night sweats, how long are you sleeping) _____________________________________________________________________________________ _____________________________________________________________________________________ What have you eaten in the last 24 hours? (include time and specific amounts) _____________________________________________________________________________________ _____________________________________________________________________________________

Are you currently experiencing any trauma-related symptoms? If not now, have you in the past? _____________________________________________________________________________________ _____________________________________________________________________________________

MEDICAL HISTORY

List any past or current diagnoses (medical and mental health): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Have you had any surgeries? If so, list date and purpose of each: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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Have you ever been in a higher level of psychiatric care (e.g., intensive outpatient program, partial hospitalization program, psychiatric inpatient treatment, residential treatment)? If so, give dates and name of treatment program: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you ever seen a psychiatrist or psychiatric nurse practitioner? If so, please give names and location:

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Has anyone in your family ever been hospitalized for psychiatric reasons or on psychiatric medication? If so, whom and for what diagnoses? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

List any prescription or over-the-counter medications you currently take, along with the dosage, frequency purpose of the medicine:

What psychiatric medicines have you tried in the past and what reactions have you had? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Medicine Dosage Frequency Purpose

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SUBSTANCE USAGE

How often do you drink alcohol? Quantity? ___________________________________________________ How often do you use marijuana? __________________________________________________________ How often do you use other recreational drugs and which ones? __________________________________ _____________________________________________________________________________________

Have you ever had any problems with drugs or alcohol? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

OTHER RELEVANT INFORMATION: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

GOALS & STRESSORS

What are the top 5 things you are stressed about in your life right now? 1. ___________________________________________________ 2. ___________________________________________________ 3. ___________________________________________________ 4. ___________________________________________________ 5. ___________________________________________________

What are your greatest strengths in dealing with the above stressors? _____________________________________________________________________________________ _____________________________________________________________________________________

What are your goals for your work in treatment at this time?

1. ___________________________________________________________________________________ 2. ___________________________________________________________________________________ 3. ___________________________________________________________________________________

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Credit Card Information 

Card Type: ☐ MasterCard ☐ VISA ☐ Discover ☐ AMEX      ☐Other ___________________________________________ 

 

 Cardholder Name (as shown on card): ___________________________________________ 

 

 Card Number: ___________________________________________ 

 

 Expiration Date (mm/yy): ___________________________________________ 

 

 Cardholder Address and Zip Code : ___________________________________________ 

 

 CCV (3-4 digit code on back of card ) :___________________________________________     

 

I, _______________________________, authorize Columbus Behavioral Health, LLC to charge my credit card above for agreed copay/ deductible amount. I understand that my information will be saved to file for future transactions on my account. 

 

__________________________________ _____________________________ 

Customer Signature Date 

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