6797 N. High Street, Suite 214
Worthington, Ohio 43085

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Office | 614.505.6949
Fax | 614.505.6558
Confidential Voicemail
614.505.6949

Office Hours

Thursday 1 p.m. - 7:30 p.m.
Friday 11:00 a.m. – 4:30 p.m.
Saturday 10:00 a.m. – 3:30 p.m.

Forms: Adults

Notice of Privacy Practices and Psychologists’ Policies
Informed Consent for Participation in Treatment
Client Information – Adult
Authorization for Signature on File
Release of Information for Primary Care Physician
Primary Insurance Information Form
Authorization for Release of Information (ROI) Form
Informed Consent for Telebehavioral Health
Family History

Forms: Child/Teen

Notice of Privacy Practices and Psychologists’ Policies
Informed Consent for Participation in Treatment
Parental Consent for Treatment of a Minor
Client Information – Child/Teen
Authorization for Signature on File
Release of Information for Pediatrician
Primary Insurance Information Form
Authorization for Release of Information (ROI) Form
Informed Consent for Telebehavioral Health
Family History

Member of

Member, Association for Behavioral and Cognitive Therapies ABCT

Member, American Psychological Association

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