STAR Institute New Client Inquiry Form

Client Legal Name (for insurance purposes):*

First NameLast Name
Client Preferred Name (if different than Legal)?
Client Date of Birth:*

MonthDayYear
Completed By:*
Name (if completed by anyone other than self):
Relationship to Client:
Primary Parent/Guardian Name*

First NameLast Name
Mobile Number:*
E-mail:*
Access to our portal will be emailed to this address
Referral Source: *
If no provider, how did you hear about us?
Country*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address*

Street Address

Street Address Line 2

CityState

Zip Code
International Address*

Street Address

Street Address Line 2

CityState

Zip Code
International Phone Number and/or Zip Code
If outside the US, do you have WhatsApp or another international communcation method?

YesNoOther
Do you have Colorado Medicaid?*

YesNo
Medicaid ID*
Are you currently receiving occupational therapy services?*

YesNo
Primary Care Doctor's Office*
PCP Name
PCP Phone Number*
Please enter a valid phone number.
PCP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP Fax Number
Please enter a valid phone number.
Do you authorize STAR to contact your PCP to support therapy, planning, care coordination, and insurance?*
I hereby authorize STAR Institute to share and obtain information regarding the evaluation and treatment of the named client above for the purposes of treatment, planning, care coordination, and insurance. I authorize the release of such information as the treating therapist deems relevant and pertinent to the professional listed above. I further authorize the professional above to release the complete information from the medical, school, social service and/or psychological records of the named client above to STAR Institute as is relevant to their care.I do understand that this release and sharing of information will include, but not be limited to conversations, therapy sessions, records, reports, determinations, evaluations, and factual information regarding myself and/or family member(s). I understand that this action is taken to assist STAR Institute to provide the best care possible for myself and my family.This authorization is voluntary and remains in effect for the duration of treatment at STAR and up to 1 year after discharge or the end of treatment. I understand that I can choose to revoke this release at any time by written notice to STAR Institute and the professional named above.
Do you have Medicare?*

YesNo
Do you plan to bill your insurance for reimbursement?*
With the exception of Colorado Health First Medicaid, STAR Institute is private pay and requires payment at time of service. We are considered out-of-network. Our billing team is happy to support you in getting the documentation needed and requesting reimbursement through your insurance. If you choose "No" our billing team will not be in contact about this option. Choosing "yes" allows for more timely support from the billing team.
Legal Sex (for insurance purposes ONLY)*

MaleFemaleIntersexOther
Gender*

MaleFemaleNon-binaryOther/Undefined
Pronouns?

She/HerHe/HimShe/TheyHe/ TheyThey/ThemOther/Prefer not to answer
How do you identify your race/ethnicity?*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinxMiddle Eastern or North AfricanNative Hawaiian or Other Pacific IslanderWhiteTwo or More RacesPrefer Not to AnswerAnother Race/Ethnicity
What services and supports are you seeking?*

Occupational TherapyFeeding/DietaryAugmentative and Alternative Communication (AAC)Safe and Sound(SSP)/Listening TherapyWhole Body HandwritingOther
Does client use any Assistive or Adaptive Devices or Durable Medical Equipment?*

YesNo
Please describe what devices and/or equipment is used.*
Any Previous Diagnoses: *
I prefer to communicate via:

Phone CallEmail
Should be Empty: