Name of Person Filling Out Form:    First Name*   Last Name*   
Phone Number of Person Filling Out Form:   Area Code*   Phone Number*   
Email of Person Filling Out Form:    Email*   

Client Name:   First Name*   Last Name*   
Client DOB:   Client DOB*   
Gender at Birth:         Type a label   
Gender Identity:                        Type a label   
Parent Name:   First Name*   Last Name*   
Parent DOB: Parent DOB*  
Parent SSN: Social Security #   
Phone Number:      Phone Number*   
Address:   Street Address      City   State   Zip   
Email: Email*   

Physician Name/Practice: Name*  
Phone Number:      Phone Number*   
Fax Number:      Phone Number   
Do you have Medicaid?   Yes/No*   
Medicaid Number:   Medicaid Number (Type N/A If Not Applicable)*    
Do you have private insurance?   Yes/No*   
Private Insurance Company Name:    Insurance Co (Type N/A If Not Applicable)*   
Private Insurance Company Number:      Phone Number*   
Policy ID: Policy ID Number (Type N/A If Not Applicable)*   
Group:Group Number (Type N/A If Not Applicable)*   
Provider Services Phone Number:      Phone Number*   
Policy Holder Name:   Policy Holder Name *   
Policy Holder DOB:   Policy Holder DOB*   
Is the policy holders address the same as above?     Yes/No*   
If no, what address?   Street Address   City   State   Zip    
Any other insurance?   Yes/No*    List other insurance company name and ID   

Referral Source:   Referral Source   
What day/time works for you on a consistent basis?
Day(s): Day(s)* Time(s): Time(s)*
What locations work best for you?   Home      Daycare   Clinic   Virtual (Speech Only)   School   
Name of Daycare/School:   Daycare/School Name   
Reason(s) for seeking therapy? *
Additional Information (Previous Services, Diagnoses, etc):