Forms & Policies
In an effort to save you time, the Sophia Center’s policies and required paperwork are included in this section.
The Office Manager will gladly check with your insurance carrier prior to your first visit to determine your benefits, deductibles and co-pays. Please fax a copy of both sides of your insurance card to: 419.885.7612. Also, bring your insurance card with you at the time of your visit. If a referral is necessary from your primary care physician, it must be in place prior to your visit. Please call the office to check whether it has been received.
Registration Form
Client Self-Pay
Authorization Form
Adult Bio Form
Child Bio Form
Registration - Lourdes Students
Art Therapy Form
Important to note:
- If a referral is necessary from your primary care physician, please be sure we have authorization prior to your visit. You may call the office a few days prior to your visit to confirm that the referral has been received. If not, your appointment should be rescheduled.
- Please fax both sides of your insurance card(s) to 419.885.7612 as soon as possible after your intake so that pre-certification and eligibility of benefits can be determined prior to your visit. You must have a conversation regarding benefits or payment plans with us prior to your visit or, at the very least, the day of your visit. You may contact us at 419.882.4529. Should your insurance change at any time during your therapy, please advise us. You are responsible for visits not authorized in this situation.
- Self-pay counseling sessions are $175 for intake and $125 for sessions afterwards. Sliding fee scales can be discussed if we do not accept your insurance or if you do not have any.
- As a courtesy to other clients, we require a 48 hour cancellation notice. If you do not call to cancel, a $50 fee will be billed directly to you. Late cancellations are subject to a $35 fee.
Should you have any other questions or concerns, please contact our office.
