Adult Client Intake

Adult Client Intake
To submit a Vision Exam Request: Please click here to be directed to our "Vision Exam Request Form"
Date:*

MonthDayYear
Insurance-Based Services Requested:

Auditory Services
Private Pay Services Requested:

Neuro Integrative ClinicNeurofeedback or Audio-Visual Entrainment (AVE)Vision Therapy
*The Neuro Integrative Clinic, Vision Therapy, Neurofeedback, and Audio-Visual Entrainment (AVE) are all private pay programs at A Chance To Grow.
Vision exam in last year?*

YesNo
If yes, please select date of Vision of exam:

MonthDayYear
Hearing exam in the last year?*

YesNo
If yes, please select date of Hearing exam:

MonthDayYear
Areas of concern:*
Client Information
Client Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Age:*
Gender:*
Race - Please check the box that most accurately reflects your race:*

American Indian / Alaskan NativeAsian / Asian AmericanBlack / African / African AmericanCaucasianMiddle EasternNative Hawaiian / Pacific IslanderMore Than One RacePrefer not to answer
Ethnicity - Please check the box that most accurately reflects your ethnicity:*

Hispanic / LatinxNon-Hispanic / LatinxPrefer not to answer
Contact Information
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Email:*
example@example.com
Client Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary language of client:*
Interpreter needed?*

YesNo
Medical Information
Allergies / Precautions:
Medical diagnosis:
Date of diagnosis:

MonthDayYear
Name of Primary Care Provider/Physician:*
Name of Clinic:*
Clinic Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Clinic Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Clinic Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Primary Insurance:*
Active as of date:*

MonthDayYear
Vision Plan?*

YesNo
Policy Number:*
Group Number:*
Policy Holder:*

First NameLast Name
Policy Holder Date of Birth:*

MonthDayYear
Secondary Insurance:
Active as of date:

MonthDayYear
Policy Number:
Group Number:
Insurance Card Front
Insurance Card Back
Photo ID Front
Photo ID Back
Preferred method of contact:*

PhoneEmailText
Please specify your preferred availability for appointments (Monday - Friday, 8:00 AM - 6:00 PM)
How did you hear about A Chance To Grow?

Primary Care ProviderFriend/Family MemberTeacher/School Staff MemberA Chance To Grow websiteA Chance To Grow staffCurrent or former A Chance To Grow client
Signature:*
Should be Empty:

Adult Client Intake

Client Information

Contact Information

Medical Information

Insurance Information