Central Ohio Behavioral Medicine. Inc.

2000 W. Henderson Rd., Suite 325
Columbus, Ohio 43220
Phone: 614.538.8300
Fax: 614.538.1656

Patient Forms

Patient Registration Form

Adult Medical History Form

Adolescent Medical History Form

Adolescent Parent History Form

Insurance Information

HIPPA Information

Informed Consent For Treatment

Informed Consent/HIPPA Signature Page

Clinician Referral Form

Release of Information Consent Form

Diagnostic Services

Comprehensive Psychiatric Evaluation of Adolescents and Adults

Treatment Services

Medication Management

Individual Psychotherapy