Make an Appointment - Office Visit Request
Shelly Grey will assist you in determining your insurance benefits and co-pay.  Shelly will set all appointment times and will phone you with a friendly reminder prior to your appointment.  Shelly will also help to clarify any billing questions that may arise.

Each insurance company varies in its procedures for obtaining authorization for service. Gaining authorization rests in the hands of each client however, our office manager will assist you by contacting your insurance before your initial visit. She will contact you prior to your visit to review estimated insurance payments and co-pay requirements.

To begin the process for an appointment please phone Shelly at 419-885-4121 or begin the process by submitting the Office Visit Request form:
Office Visit Request
Name:    
Contact:    
Date Requested:  mm/dd/yyyy  
Preferred Appointment Time:   
Phone:    
Cell:    
Preferred Call Back Time:   
Type of Service Requested:
 
Therapist:    
Birth Date:  mm/dd/yyyy    
Address:    
City:    
State:    Zip:     
Fax:    
Email:  
Comments:
Insurance Information
  Primary
Insurance
Secondary Insurance
Name of Insurance Carrier:
Policy Holder's Name:
Employer:
Contract Number:
Insurance Number:
   

You may complete the forms needed for an office visit on-line by printing and filling out forms # 1, 2 and 3 prior to your visit or arrive 20 minutes before your first appointment to fill them out at the office.

Form      Contents
#1  Client Information
Psychological Services Fee Structure
Insurance Payments/Denials
Deliquent Account Collection Procedure

[Print]
#2  Client Medical History

[Print]
#3  Psychotherapist-Patient Services Agreement
HIPPA Veification form

[Print]
#4  Ohio HIPPA Notice Form
  (Print and keep for your records)

[Print]


If you are requesting a Training Seminar, Presentation or Consultation, click on
Presentation Request.