Patient Intake Form

Patient Intake Form

Please complete this form to provide your personal, medical, and insurance information for your healthcare provider.
Client Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityStateZip Code
Date of Birth*

MonthDayYear
Date
Primary Insurance Carrier
Upload a photo of your insurance card (Front)

(optional)
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Upload a photo of your insurance card (Back)

(optional)
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Member ID
Secondary Insurance Carrier
Secondary Member ID

Emergency Contact Information

(Other than Parent/Guardian)
Primary Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Client*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Client*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Diagnosis
Primary Diagnosis*
e.g., autism, speech delay, developmental delay
Diagnosis Date(s)*
Diagnosing Professional*
neurologist, developmental pediatrician, or primary care physician
Diagnosis Document

(optional)
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Please note that the diagnosis information is required for insurance coverage. By having this information, it assists us when speaking with your insurance company to get authorization for services and providing you with invoices for reimbursement through insurance.
Home BasedClinic BasedSchool BasedSocial Skills Group

Consent and Signature
Authorization to Release Information*
Authorization to Bill Insurance*
Authorization to Release Medical Information to Insurance Carrier*
Mandated Reporting Policy Acknowledgment Form*
Notice of Privacy Practices: Health Insurance Portability and Accountability Act (HIPAA)*
Injury & Incident Reporting Protocol Acknowledgment Form*
A to Z Behavioral Services Telehealth and Virtual Services Consent Protocol*
A to Z Clinic Attendance Policy*
Parent Clinic Handbook*
AcceptDecline
Playground Use Waiver And & Consent*
Signature*

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Client Information