Bethel Olentangy Psychological Services

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Forms and Paperwork

Document Library

NameDescription
DocumentTelehealth Consent FormConsent form for those participating in telehealth services
DocumentPayment Authorization FormA payment method on file is required
DocumentRelease of InformationComplete this form to give permission for account and/or treatment information to be released to a third party
DocumentHIPAA NoticeOur policies and Practices to Protect the Privacy of Your Health Information
DocumentRelease of Information (Spanish)Complete este formulario para autorizar que la información de su cuenta y/o tratamiento sea divulgada a un tercero.

Document Library

NameDescription
DocumentAdult PaperworkPaperwork for patients that are 18 and older to complete as a new patient, returning patient that has not been seen in a years time, or a patient that has recently turned 18 years of age
DocumentChild PaperworkPaperwork for new patients or returning patients that have not been seen in a years time who are under 18 years of age
DocumentAdult Paperwork (Spanish)La documentación para pacientes que tienen 18 años o más deben llenarla como pacientes nuevos, pacientes que regresan y que no han sido atendidos en el plazo de un año, o pacientes que recientemente han cumplido 18 años.

If you need to schedule a new patient appointment, complete the online intake form listed under the Intake tab or contact the intake coordinator at (614) 451-6606.