Pre-Scheduling Questionnaire

Pre-Scheduling Questionnaire
Patient's Legal Name*

First NameLast Name
Patient's DOB*

MonthDayYear
Date
Your relationship to the patient:*

SelfOther
Preferred email address*
example@example.com
Preferred phone number*
Please enter a valid phone number.
If the patient is a minor, who has legal custody of the patient?*

Not applicableParents are married + share joint legal custodyParents are separated/divorced + share joint legal custodyOther
Patient's grade, if applicable
What services are you seeking in our office? (Check all that apply.)*

Therapy ServicesTesting ServicesMedication ManagementExecutive Function Coaching / Academic Tutoring ServicesEducational Consultation ServicesCo-Parenting CoachingPediatric MD ServicesOther
What insurance do you have?*
Do you have concerns regarding any of the following pertaining to the patient? (Check all that apply.)*

ADD / ADHDA potential learning disorder (such as dyslexia, dysgraphia, processing issues, reading / math comprehension, etc.)Autism spectrum disordersSeeking gifted / admissions testingSeeking to identify strengths / weaknesses within learningOther
What are the primary concerns you'd like to address at this time?*
Do you have any safety concerns with regard to the patient? This can include, but is not limited to, suicidal ideation, self-harming behaviors, homicidal ideation, hallucinations, etc.*
Would you be able to attend sessions during the mornings or early afternoons? (Some providers may have limited late afternoon / evening availability at this time.)*

YesNo
Are you being court-ordered to seek services?*

YesNo
Is there anything else you'd like us to know that will help us match you with the appropriate services and provider?
How did you hear about us?
PLEASE NOTE: If it seems you have not received a response within 48 business hours, please check your spam folder.
Please be sure to click the submit button below!
Important Practice Information

Please note that our practice does not offer after-hours services. Patients experiencing life-threatening emergencies outside of their provider's normal business hours must dial 911 or report to their nearest emergency room. Patients with urgent treatment needs should not expect a response outside of normal business hours.
Network Participation

While not all of our providers participate with insurance, those that do participate solely with Anthem commercial plans. In the event that your provider is not in-network with your insurance plan, our practice can provide you with a superbill so that you can file out-of-network claims on your own behalf if your plan has out-of-network benefits. Please note that WFP providers do not participate with Medicaid or Medicare at this time.
Should be Empty:

Pre-Scheduling Questionnaire

Please be sure to click the submit button below!

Important Practice Information

Network Participation