GANC Appointment Request Form 2023

Appointment Request Form
Please select a service:*

Neurodivergent Girl Power Group (AGES 12-22 years old)
IMPORTANT INFORMATION:
- Appointment slots are first-come, first-served and in-person after school/evening availability is limited.
- We DO NOT bill insurance for these services.
- Our office DOES NOT provide medication or prescriptions. Please refer to your primary care physician or a psychiatrist for medication.
- You MUST be in the state of Texas at the time you receive video services. Our clinicians are not licensed outside of Texas.
IMPORTANT INFORMATION:
- This is a 8-week group that is broken up into middle school age, high school age, and young adult
- This group is NOT covered by insurance
- You MUST be in the state of Texas at the time you receive video services. Our clinicians are not licensed outside of Texas.

CLIENT INFORMATION - CONTINUED
Client's Name*

First NameLast Name
Client's School Campus and Grade*

School CampusGrade
Client's DOB*

MonthDayYear
Date
Client's Primary Language*

EnglishSpanishOther
Is there any other language spoken in the home or that the client understands?*
This helps pair you with the most appropriate clinician
Has the client had a previous psychological evaluation?*
This helps pair you with the most appropriate clinician
Does the client have a medical/psychiatric diagnosis?*
This helps pair you with the most appropriate clinician
Client's Address

Street Address

Street Address Line 2

CityState

Zip Code
Client's Phone Number*
Client's Email Address*
example@example.com
* We require a copy of the client's state I.D. be uploaded to this form to process appointment requests.
Upload Copy of Client's State/Government Identification Card or Driver's License*

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PARENT / LEGAL GUARDIAN'S CONTACT INFORMATION
Your Name*

First NameLast Name
Marital Status
Relationship To Client
Step-parents will NOT be able to schedule or sign consent forms for the minor unless you have proof of adoption. Please make sure to include biological parent's contact information as well as we will need to communicate through them first.
Your Primary Language

EnglishSpanishOther
Your Secondary Language
Is your address the same as the patient's address?

YesNo
Who does the child primarily live with?
Your Address

Street Address

Street Address Line 2

CityState

Zip Code
Your Phone Number*
Your Email Address*
example@example.com
* We require a copy of one the adult parent/guardian's state I.D. be uploaded to this form to process appointment requests.
Upload Copy of Your State/Government Identification Card or Driver's License*

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Additional Parent/Guardian's Name

First NameLast Name
Relationship To Client
Step-parents will NOT be able to schedule or sign consent forms for the minor unless you have proof of adoption. Please make sure to include biological parent's contact information as well as we will need to communicate through them first.
Is Additional Parent's address the same as the minor patient's address?

YesNo
Additional Parent/Guardian's Address

Street Address

Street Address Line 2

CityState

Zip Code
Additional Parent's Phone Number
Additional Parent's Email Address
example@example.com

ADDITIONAL PATIENT INFORMATION
Please provide a brief description of the concerns/issues: *
How did you hear about us?*

Google/Internet SearchFacebook/Social Media AdFamily/FriendPCP/PediatricianPsychiatrist/TherapistOther
If it was a Mental Health/Medical professional, please share who?
Should be Empty:

Appointment Request Form