New Patient Inquiry

New Patient Inquiry

Please fill in the form below
Patient Name

First NameMiddle NameLast Name
Sex
Patient Date of Birth

MonthDayYear
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Therapy or Therapies Interested in:
Please tell us about your child's development and what concerns led you to seek therapy. What would you most like help with?
Is your child currently receiving or has your child previously received therapy services?
Which therapies has your child received, and where?
Do you have a recent evaluation or therapy report you would like to share?"
If yes, when?
If yes, please upload any pertinent evaluations or therapy notes:

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Parent/Guardian Contact Information

Please complete the following section if the patient is a child:
Primary Parent/Guardian Name:

First NameLast Name
Primary Parent Email
example@example.com
Primary Parent Contact Number:

Area CodePhone Number
Preferred Method of Contact
Preferred Language for Communication:
Name of Pediatrician/Primary Care Provider:
Name of Pediatrician Practice:
Insurance Information
Is the patient covered by insurance?
Insurance Company: *
ID #: * Group #: *
Effective Date:
Primary Insured: *
Relationship to Patient: *
DOB of Primary Insured: *
Customer Service Provider Phone Number: *
Take Photo of Front of Insurance Card
Upload the front of the insurance card

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Upload the back of the insurance card

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Is the patient covered by secondary insurance?
Secondary Insurance Company: *
ID #: * Group #: *
Effective Date:
Primary Insured: *
Relationship to Patient: *
DOB of Primary Insured: *
Customer Service Provider Phone Number: *
Upload Front of Card:

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Upload Back of Card:

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I understand that if I have BOTH primary and secondary insurance policies that this makes my claims subject to coordination of benefits and subject to the rules and regulations of each separate policy.
Is the patient covered by Medicaid:
If patient is covered by Medicaid complete the following:
Medicaid #:
Name of Person Completing:

First NameLast Name
Relationship to Patient:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

New Patient Inquiry

Parent/Guardian Contact Information

Insurance Information