Self or Guardian Referral for Services – Mid-Ohio Psychological Services

Please complete the below referral for service form. If you are submitting on the behalf of a potential client, please obtain client/guardian’s consent prior to completing the referral. Please note that the information will be submitted electronically and may not be secured. Once your submission has been received, a staff member will be in contact within two business days. For further information about the services we offer please refer to our Services page.

In the event of an emergency or need to speak with a clinician immediately, please visit your nearest emergency department or Netcare Access (http://www.netcareaccess.org/). If you are experiencing a crisis or have an urgent need, please contact National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). Additionally, there is a Crisis Text Line that serves anyone in any type of crisis. It is available by texting “HOME” TO 741-741. Fairfield County ADAMH Crisis Brochure.

Referral

Please complete the fields entirely. At anytime if you would rather complete the scheduling and registration process instead of submitting the information electronically please contact us at 740-687-0042 and we would be happy to walk you through the intake process.

Person completing referral form

First Name

Last Name

Referral Source Agency (if applicable)

Email for person completing the form:

Referral Source Phone Number:

Does the client/client's guardian know that you are making this referral?

Background Information

Client's Name *

First Name:

Last Name:

Guardian's Name (if applicable)

First Name:

Last Name:

Client/Guardian Phone Number *

Secondary Phone Number

Client's Date of Birth *

Client's Address *

Country

City

State

Zip code

Apt. suite, etc.

Country

Social Security Number

Client Email Address *

Services Requested *

Diagnostic Assessment for Treatment (includes treatment plan, no formal report)

Counseling

Case Management Services/Therapeutic Behavioral Services

General Psychological Evaluation (includes report writing fee)

Focal Evaluation (includes report writing fee)

What is the reason you are seeking services? *

Do you know of any family members that have received services at our agency? Are you aware of any conflicts with any of our staff?

Are there certain days and times that may work best for you? We cannot guarantee a certain time or day, but we will try to accommodate to the best of our ability. It is important to note that we have very limited evening and weekend hours.

Is there any assistance that you may require for your appointment? Will you need any accommodations?

Registration Process

County of Residence

County of Origin

Federal guidelines mandate that we collect data on the legal sex of all clients. Please report the sex currently listed on your social security card.

What is your living arrangement?

How do you identify your race? *

Do we have permission to access your client eligibility and benefits information? *

What is your primary payment arrangement? *

Please select your insurance provider:

Policy Number

Billing Number

Claims Address

Subscribers Name

Subscribers Date of Birth

Subscriber ID

Group #

Insurance Phone #

Deductible/Co-Pay (if you know it)

Managed Care Plan

Please enter your Member ID:

Please enter your MMIS Number:

The following questions ask about Court or Child Protective Services involvement, they can be skipped if they are not relevant to the client

System Involvement (select all that apply - skip if not relevant)

Caseworker/Probation Officer (if applicable):

Court/County (if applicable):

Were you referred?

Please specify the referral source:

Please Specify the name of the referral source

How did you hear about us?

At this time we offer office-based and telehealth sessions. For safety measures we have very limited office-based sessions available. We will try to accommodate your request, however given limited availability we may not be able provide office-based sessions.

Would you prefer sessions (payor permitting)?

How would you like to schedule your appointment? *

reCAPTCHA is required.