Intake Form

New Patient Intake

Please click the save button at the bottom of the page if you need to leave the form and come back to it later.
Date

MonthDayYear
Date
Child's Name

First Legal NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Current Date

MonthDayYear
Age
Sex
Parent/Guardian 1

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
1
By providing your email address/phone number, you agree to be added to our clinic’s mailing/texting list. We use this list to send important updates, including appointment reminders, clinic closures, upcoming events, and community happenings, as well as occasional promotions. You may unsubscribe at any time.
Parent/Guardian 2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
Address of Parent 2 (if different from child)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us? Please be specific and include the name of the person who referred you to us. We'd like to express our gratitude to them!
If it's a doctor, please write name and address of the provider:
Please describe your specific concerns in requesting an evaluation/services for your child:
Does your child have a formal diagnosis?
If yes, what is it?
When was it made?
Please upload any available documentation that supports the diagnosis.

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Type of service needed:
Type of evaluation(s) needed:

Other
Type of therapy needed:

Other
If your child has already been evaluated and/or has received evaluations pertinent to your concerns please upload them here. This information is very helpful in our ability to make evaluative and therapeutic decisions.

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Location:
What do you hope to gain from our services?
What are your goals and aspirations for your child?
Has your family experienced any recent crisis or stress that you feel is impacting your child's development at this time?

Please fill in your child's availability to receive therapy for each day between the hours of 7:30 am and 7:00 pm (Please note, our office hours are until 5:30 PM on Fridays and 3:00 PM on Saturdays). Remember to allow for travel time. If your child is not available on a particular day, please indicate "not available". Please give as much information as you can, as this will support our ability to place your child for therapy if needed.

Rows	Availability for Therapy (Start time- End time)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Please note that CSS is in-network with Cigna and Aetna for services for speech-language/AAC and feeding therapy. We are happy to bill your out-of-network provider for all other services. We are not certified to bill Medicaid.
Insurance card front

*Please provide a copy of your insurance card (front & back) for all insurance companies.
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Insurance card back

*Please provide a copy of your insurance card (front & back) for all insurance companies.
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Insurance CO: Insurance CO
ID#: ID #
Group #:   Group #
Policy Holder's Name:   First Name*   Last Name*
Policy Holder's Date of Birth:   DOB*
Signature
Should be Empty:

New Patient Intake