Patient Intake Form
Child's Name
*
First Name
Last Name
Child's DOB
*
-
Month
-
Day
Year
Date Picker Icon
Child's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Gender
*
Female
Male
Non-binary
Other
Primary Contact Name
*
First Name
Last Name
Primary Contact Email
*
example@example.com
Primary Contact Phone
*
-
Area Code
Phone Number
Please list ALL diagnosis' that your child has.
*
Please list referring physician (PCP) name
*
Please list PCP phone # and location
*
Insurance
Please Select
Self-Pay
WellCare
Amerigroup
SSI
Katie Becket/Deeming Waiver
Medicaid
Effective 2/1/2023, our practice will no longer accept patients with Peachstate insurance.
Please list Medicaid Number (if applicable)
*
Please indicate days/times that are best for your child to be seen.
*
Please list what you hope to accomplish through our services. What are some goals you have for your child.
*
Submit
Should be Empty: