5655 N. High Street
Worthington, OH 43085-3948

Tel: 614-505-6977

Fax: 614-505-3548

General Hours:
Mon-Thu: 9:00am - 8:00pm
Fri: 9:00am - 4:00pm
Get Directions

New Patients: Intake Paperwork

Several forms are available here, for the convenience of our clients. Please click on the links for a PDF file of any necessary paperwork.

If you choose to print and complete any forms, you may bring them in on the date of the scheduled appointment. You may also fax them to our office with a cover sheet indicating: the date and time of the appointment, and the clinician the patient will be seeing.

If you need to download a free version of Adobe Reader, please click the link below to be directed to their webpage.

Get Adobe Reader

If you are seeing a psychiatrist, (Dr. Ajay Sharma, M.D.) please fill out the following paperwork - Psychiatrist intake

If you are seeing a therapist , (Kimm Cynkar, Cheryl Hamilton, Kevin Hamm, Steve Martin, Jackie Schwartz, Jack Stoneburner, or Danuta Van Beysterveldt) please fill out the following paperwork - Intake

Please be aware that you may have additional paperwork to fill out when you arrive for your appointment depending on the clinician you are seeing.

If you have any questions, please give us a call at (614) 457-8359.

ALL FORMS

Intake
Psychiatrist intake

FAQ SHEETS

DBT Info
DBT FAQ