Let's Get You Started Therapy Prescreen To get you the right help we would like to know a little bit about you. Please use the form below to submit your information – Therapy Prescreening Form Please enable JavaScript in your browser to complete this form.Name *Email *Phone *Date Of Birth *Briefly, what is bringing you to counseling? How long have you felt like this? *Are you having thoughts of hurting yourself or anyone else? (Yes/No)Has anything significant happened to increase these feelings recently?Which therapist have you selected to work with? *Have you done counseling before in the past? *Insurance/Self Pay *AetnaAetna Better Health (Medicaid)Anthem BCBSBuckeye MedicaidCaresourceCignaOhioHealthyOhio MedicaidOSU (student or staff)Medical MutualSelf PaySubmit
