Please Print and Fill Out The Following Forms and Bring
Them to Your First Appointment
Adult Self Report
Adult Self Report
Intake Demographics

COC's Policies

Late Cancellation/Missed appointment policy

COC requires a 24 hour notice if you are cancelling your appointment. If you fail to contact our office at least 24 hours prior to your scheduled appointment or if you do not show for your scheduled appointment we will charge you a $60 fee for the late cancellation or no show.

Prescription refill policy

Your prescriptions will be filled at your regularly scheduled appointment. If you find that you need refills prior to your appointment your doctor may charge a $25 refill fee for these prescriptions. Please note that it is at your physicians discretion as to whether he/she will refill controlled medications. In most instances you will need to be seen for an appointment for these medications to be refilled. Also, please note you will need to contact our office to request any refills as we do not honor faxed prescription requests from your pharmacy. Please allow 2 business days for refills to be processed. We will not process refill requests after 12pm on Friday or over the weekend.

Medical Records Requests

if you are requesting medical records please click on the Release of Information link to download a release to send medical records. Please fill out the release in its entirety and fax to our office at 614-785-0095. If you are requesting records be forwarded to another physician we will be happy to send them via fax at no charge. If you are requesting a paper copy of medical records for personal use we reserve the right to charge a reasonable fee for time and supplies. Please allow 7 business days for medical records requests to be processed.

Disability Forms

COC does not provide disability assessments nor will our providers fill out paperwork for disability claims. If you are currently on disability or seeking disability please be advised of this policy.

Call us today at 1.614.785.1115

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1035 Proprietors Road • Worthington, OH 43085

Office phone: 614-785-1115  •  Office fax: 614-785-0095

© 2020 by Central Ohio Counseling, Inc.