Please only complete at the direction of our therapist or Office Manager. Call (740) 924-7543 or email Info@pbjconnections.org for the most accurate information on our wait-list.
The following forms should be completed and returned to us via fax (740-924-2002) or paper mail (9734 Jug St. NW Pataskala, OH 43062). Once we receive these forms we will contact you to schedule an intake appointment.
The facilities where we deliver our services require liability waivers in addition to those forms required for program admission. Please check with us to determine which of these waivers you are required to complete.
These two forms should be completed if they are applicable to your situation.
Here is some additional information on our treatment and privacy policies. These forms will be provided at your intake appointment.
- Privacy, Policy & Signature Forms – Consent for Treatment and Payment Agreement