Social Skills Program Pre-Scheduling Questionnaire
with Kara Leslie, Ed.S., NCSP, BCBA
Patient's Legal Name
*
First Name
Last Name
Patient's Preferred Name (if applicable)
Patient's DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your relationship to the patient:
*
Self
Other
Preferred email address (you will be contacted directly via email for scheduling)
*
example@example.com
Patient's grade (if applicable)
*
Do you have concerns regarding any of the following pertaining to the patient? (Check all that apply.)
*
ADD / ADHD
Autism spectrum disorders
Seeking to identify strengths / weaknesses within social settings
Social Anxiety
Other
What are the primary concerns you'd like to address at this time?
*
Are there specific goals or skills you'd like to be achieved during this process?
*
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.
*
The individual and group sessions will be scheduled on Monday-Friday afternoons between 12:30 and 3:30. Beginning in July, mornings and later afternoon appointments will be available as well. Please provide days and times of availability based on this timeframe. Appointments will be 45-minutes long.
*
PLEASE NOTE: This service is not billable to insurance plans. This will be a self pay service only.
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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.
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