New Client Inquiry for Dr Nerissa Bauer

Dr Nerissa Bauer

NB Behavioral Pediatrics

12735 Meeting House Road

Suite 200, Carmel, IN 46032

www.letstalkkidshealth.org/private-practice

Amy Barnes

Executive Assitant to Dr Bauer

QbTest Technician
New Client Request Form

I am excited that you are interested in my private practice. Because I am also the CEO of Let's Talk Kids Health, I only have a limited number of private practice clients I can take on. If you are interested in joining my private practice, please fill out the following request form. Please note that due to licensing, I can only accept private practice clients in the state of Indiana. I also DO NOT accept insurance. I specialize in the diagnosis and behavioral treatment of children and tweens between the ages of 2 and 21. Common conditions I treat include attention deficit hyperactivity disorder (ADHD), anxiety, depression and parenting issues. If accepted into my practice, please note that the INTAKE will be 90 minutes and IN PERSON. Follow up appointments range from 30-60 minutes. A fee schedule will be provided prior to scheduling any appointments. Upon reviewing this form, a team member will reach out to you about next steps. You should hear back within 72 hours of completing the form. If you do not see a response, please check your spam and junk folders. If you need assistance, please send an email to amy@letstalkkidshealth.org
Parent/Adult Caregiver Information

First NameLast Name
Parent/ Adult Caregiver Preferred Email
example@example.com
Parent / Adult Caregiver #2 (if applicable)

First NameLast Name
Family Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Information

First NameLast Name
Child Date of Birth

DayMonthYear
Gender
Phone Number
Consent to contact via email

YesNo
Consent to contact via SMS/Text

YesNo
Briefly describe why you are wanting your child to see me
Has your child ever been diagnosed or treated for any of the following?

ADHD/Attention Deficit Hyperactivity DisorderAnxietyDepressionAutismSensory Processing DisorderSpeech/language issueDevelopmental DelayDisruptive Mood Disregulation DisorderEating DisorderTrichotillomaniaTics (vocal or motor)/TourettesSleep problemsLearning Disability or school output failureNone/not applicable or no known diagnosis at this time
Is your child currently enrolled in MEDICAID?

NoYes
Is your child currently on medication for behavior/mental health issues?

YesNo
Is your child currently receiving therapy for any behavioral or mental health issues? (Please note that I do not offer long term therapy but can refer you to therapists as needed).

YesNoOn wait list for therapy
Dr Bauer is also an ADHD Coach and she interweaves coaching in follow up appointments with families. However she has limited slots for 1-1 coaching for teens and adults. Are you filling out this form specifically for ADHD coaching? These are virtual and only open to a limited number of clients.

YesNot sure, I need to know more
How did you learn about me and my direct specialty care practice?

Facebook groupInstagramLinkedInYouTubePediatrician or Child's Family Physician/Nurse PractitionerTherapistFamily/friend/work colleague/ past or current private practice client of Dr Bauer'sTook Dr Bauer's TEACH Me ADHD CourseMember of Dr Bauer's ADHD Sleuth's CommunityADHD Mom Docs PodcastGoogle SearchOther
Who can I thank for referring you to me?
I send out a weekly newsletter with updates about my practice, and offerings and events on my online educational platform (Let's Talk Kids Health). This is a way I like to update my clients. Can I add you to my email list? I promise I will never sell your information to other parties or spam you. You can always opt out or manage your subscription preferences at any time. Please note, opting out may mean you will NOT receive any emails in the future if you register for my TEACH Me ADHD Course. If you consent, enter in your preferred email to use here.
example@example.com
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