Sophia Center is a sponsored ministry of the Sisters of St. Francis of Sylvania and is a member of Sylvania Franciscan Ministries

Registration – Lourdes Students

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.

Make secure online payments here.

Registration Form

Registration Form

Download the form to fill out and register.

Download PDF

Client Self-Pay

Client Self-Pay

Download the form for Self-Pay information.

Download PDF

Authorization Form

Authorization Form

Form to authorize Release of Records.

Download PDF

Adult Bio Form

Adult Bio Form

Download the form to fill out Adult biographical information.

Download PDF

Child Bio Form

Child Bio Form

Download the form to fill out Child biographical information.

Download PDF

Registration - Lourdes Students

Informed Consent

Form to fill out Informed Consent for TeleMental Health services.

Download PDF

Art Therapy Form

Art Therapy Form

Download the form to fill out and sign.

Download PDF

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.
  • If you are utilizing EAP sessions, authorization must be received before your first visit and not later than two days before your first session. Otherwise, your insurance carrier not EAP, will be billed for services to date. If there is anything your carrier requires from us, please let us know.
  • 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.
  • Payment contracts and scholarship opportunities are available but must be in place before service commences. Please feel free to discuss these options.
  • As a courtesy to other clients, we require a 48 hour cancellation notice. If you do not call to cancel, a $25 fee will be billed directly to you.

Should you have any other questions or concerns, please contact our office.

Color Bars