Please be advised that we do not conduct assessments for learning disabilities.
Patient's Legal Name
*
First Name
Last Name
Patient's Chosen Name, if Other than Legal Name
Patient's Pronouns
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Medical Record or GHC Member Number
Patient's Insurance
Interpreter Needed?
Yes
No
If Yes, Which Language?
Please Select
English
Afrikaans
Albanian
Arabic
Armenian
Basque
Bengali
Bulgarian
Catalan
Cambodian
Chinese (Mandarin)
Croatian
Czech
Danish
Dutch
Estonian
Fiji
Finnish
French
Georgian
German
Greek
Gujarati
Hebrew
Hindi
Hmong
Hungarian
Icelandic
Indonesian
Irish
Italian
Japanese
Javanese
Korean
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Maltese
Maori
Marathi
Mongolian
Nepali
Norwegian
Persian
Polish
Portuguese
Punjabi
Quechua
Romanian
Russian
Sanscrit
Samoan
Serbian
Slovak
Slovenian
Spanish
Swahili
Swedish
Tamil
Tatar
Telugu
Thai
Tibetan
Tonga
Turkish
Ukrainian
Urdu
Uzbek
Vietnamese
Welsh
Xhosa
Parent/Guardian
*
First Name
Last Name
Patient or Parent/Guardian Phone Number
*
Please enter a valid phone number.
Referring Provider
*
Referring Provider Email
*
example@example.com
Referring Provider Phone Number
*
Please enter a valid phone number.
Referring Provider Facility
*
What diagnostic questions do you have for the patient (e.g., Autism Spectrum Disorder, Intellectual Disability)?
*
As a reminder, we do no conduct assessments for learning disabilities.
Patient records available via electronic medical records
Patient records will be sent via fax to GHC HIM at 608-221-2646
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