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New Patient Intake
Please note:
Our New Patient Intake process takes approximately 20 minutes to complete by phone.
By completing the brief form below, you can reduce that time significantly.
We look forward to being of service!
Patient's Information:
*
Indicates required field
Please Select:
*
New Patient
Re-evaluation
Please Select:
*
Child
Adult
Patient Name
*
First
Last
Date of Birth:
*
Referred by:
*
How may we help you?
*
Age:
*
Sibling of Patient:
*
Does your child have troubles with...?
*
Attention and Focus
Learning problems
Socialization
Behavior
Obsession Compulsive Disorder
Defiance
Anxiety
Depression
None of the above
Check all that apply
Any developmental challenges?
*
Speech/Language delays
Academic delays
Coordination concerns
Sensory concerns
None of the above
Does your child have history of/ or thoughts of...?
*
Suicidal thoughts
Bipolar Disorder
Self Harm
Hair pulling/Trichotillomania
None of the above
Mother's Information:
Name
*
First
Last
[object Object]
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Please write unknown or same as below, if applicable.
Phone Number (Cell)
*
Phone Number (Home)
*
Father's Information:
Name
*
First
Last
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Please write same as above or unknown, if applicable.
Phone Number (Cell)
*
Phone Number (Home)
*
Marital Status of Parents:
*
Married
Live Together
Other
Which should we use as primary contact?
*
Mother
Father
If other, please clarify:
*
What insurance do you carry?
*
Policy Holder Name:
*
Policy Holder D.O.B.
*
ID/Membership Number:
*
Group Number:
*
Provider Phone Number: (back of card)
*
P.O. Box (if applicable - on back of card)
*
Submit
