New Client Appointment Request 2024

N648 Client/N648 Cliente
Client Name/Nombre Del Cliente:*

First NameLast Name
Client DOB/Cliente DOB:*

MonthDayYear
Date
Contact Name/Nombre De Contacto:*

First NameLast Name
Contact Phone Number/Número De Teléfono De Contacto:*
Please enter a valid phone number.
Contact Email/Correo Electrónico De Contacto:*
example@example.com
Relationship to the Client/Relación Con El Cliente: *
Lawyer's Name/Nombre el Abogado:*

First NameLast Name
Lawyer's Email/Correo Electrónico Del Abogado:*
example@example.com
Lawyer's Phone Number/Número De Teléfono Del Abogado: *
Please enter a valid phone number.
Please provide the timeline your lawyer has given you as well as any relevant information you would like to share/Proporcione el cronograma que le ha proporcionado su abogado, así como cualquier información relevante que desee compartir:*
PLEASE SELECT SUBMIT/POR FAVOR SELECCIONE ENVIAR

Reason for Services
Please provide a brief description of the concerns for seeking services: *

Reason for Services
Please Provide Reason for Testing: *
Is this for an Application for a Program or School IEE?
If IEE, what School & School District?
Is this for Gifted and Talented Identification?
If Applicable, please list any specific tests or types of testing required by the Program or School:
example: academic, emotional, learning, behavioral, cognitive testing

Adult Client
Are you scheduling for yourself?*

Yes, I am the adult client.No, I am not the adult client.
By law we can only reach out to the adult client to schedule services. If you are not the adult client, you will not be able to schedule on their behalf without being their court appointed guardian.

Parents cannot schedule for their adult children.
Do you have legal guardianship, conservatorship, or power of attorney to request services on behalf of this adult?*

Yes, I have legal guardianship, conservatorship, or power of attorney to request services on behalf of this adult patient.No
You can expedite the scheduling process by uploading a copy of the legal guardianship, conservatorship, or power of attorney decree at this time. Would you like to upload a copy now?*

Yes, I will upload decree now.No, I will provide it to Grace Psychological Services in the client portal when I am added in and I understand I will not be scheduled until I share it.
Legal guardianship, conservatorship, or power of attorney decree - Upload

Cancelof
Client's Name*

First NameLast Name
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
Client's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Client's Phone Number*
Client's Email Address*
example@example.com
Upload Copy of Client's State/Government Identification Card or Driver's License*

Cancelof

Referral
How did you hear about us?*

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

Thank you for your interest in Grace Psychological Services!

At this time, we only have virtual appointments and day time therapy appointments.

N-648 Clients Please Read Before Moving Forward

Clientes del formulario N-648, por favor lean antes de continuar

IMPORTANT INFORMATION ABOUT OUR THERAPY AVAILABILITY:

IMPORTANT INFORMATION ABOUT PSYCHOLOGICAL EVALUATION/TESTING:

N648 Client/N648 Cliente

PLEASE SELECT SUBMIT/POR FAVOR SELECCIONE ENVIAR

Reason for Services

Reason for Services

INSURANCE PAYER INFORMATION

No Worries! If you have Out-Of-Network benefits, we can provide you with Superbills for you to submit to your insurance for possible reimbursement.

We are required by law to have a copy of the FRONT and BACK of the insurance card to be uploaded in order to process benefits and claims.

Adult Client

By law we can only reach out to the adult client to schedule services. If you are not the adult client, you will not be able to schedule on their behalf without being their court appointed guardian.

Minor Client

For HIPAA we are required to have a signed copy of the custody decree in the cases of sole custody, shared custody, guardianship appointed by the courts, or adoption. If no custody decree is in place, we will need both biological parent's contact information on file.

PARENT / LEGAL GUARDIAN'S CONTACT INFORMATION

Step-parents will NOT be able to schedule or sign legal consent forms for the minor unless you have proof of adoption.

Step-parents will NOT be able to schedule or sign legal consent forms for the minor unless you have proof of adoption.

Referral