Patient Information
Please complete as accurately as possible.
Today's Date:
*
-
Month
-
Day
Year
Date
Patient's Name:
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Gender:
*
Male
Female
Other
What are your main concerns about your child:
Diagnosis (if applicable):
List current medications (if applicable):
Patient's current physician:
*
Physician's office/clinic name:
*
Contact Information
Parent/guardian's name:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Emergency contact:
*
First Name
Last Name
Contact's relationship to patient:
*
Contact's phone:
*
-
Area Code
Phone Number
I give my permission to send text messages to my personal cell phone:
*
Yes
No
Mobile phone, if different from above:
-
Area Code
Phone Number
Insurance/Medicaid Information
Primary Coverage
*
Insurance
Medicaid
Private Pay (cash/check/cc)
Other
Secondary Coverage
Insurance
Medicaid
Private Pay (cash/check/cc)
Other
Primary Card Holder Name
Primary Card Holder's DOB
-
Month
-
Day
Year
Date
Relationship to Primary Card Holder
Please Select
Self
Parent
Spouse
Other
Referral Information
How did you hear about us?
Please Select
Doctor/Dentist Referral
Facebook/Instagram
School Staff or SLP
Website
Friend/Family
Who can we thank for the referral?
We take feedback seriously, please let us know how we can improve the intake process:
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