CCPT Interest Form

First Contact Intake Form
Thank you for Reaching Out!

Before we begin scheduling your first appointment, we will need to gather some information about you and your child. Please fill this form out to the best of your ability, and we will be in touch shortly! If you have any questions or concerns, please text our admin line at (984) 300-4002. We look forward to connecting with you.
Child's Full Name
Child's Date of Birth

MonthDayYear
Child's Sex Assigned at Birth
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Name of Pediatrician Practice
If your child sees a specific doctor within the practice, please list their name.
Parent/Guardian Full Name (1)
Parent/Guardian Phone Number (1)
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address (1)
example@example.com
Parent/Guardian Full Name (2)
Parent/Guardian Phone Number (2)
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address (2)
example@example.com
Which services are you interested in?

Other
Preferred location for services
Preferred location for services
If "Other", please name your child's current preschool/daycare/center
Other location for services
Address of your child's preschool/daycare/center if "Other"

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What are your concerns for your child?
Available Days for Appointments
Available Times for Appointments
Insurance Verification

We provide verification of insurance benefits and eligibility as a courtesy to you prior to scheduling appointments. Please indicate your insurance status and provide insurance details below. A Benefit Summary Sheet will be sent to you via email, outlining the estimated out-of-pocket costs for services. ***NOTE: THIS IS ONLY AN ESTIMATE AND DOES NOT GUARANTEE COVERAGE***
Please indicate your insurance status:

Other
Primary Insurance

Please provide your primary insurance information below.
Primary Insurance Carrier
Insurance Carrier
Primary Member ID
Member ID
Primary Group Number
Group Number
Primary Policyholder Name

First NameLast Name
Primary Policyholder DOB

MonthDayYear
Is Prior Authorization required for services?
Upload the front of your insurance card

Cancelof
Upload the back of your insurance card

Cancelof
Secondary Insurance

Please provide your secondary insurance information below.
Secondary Insurance Carrier
Insurance Carrier
Secondary Member ID
Member ID
Secondary Group Number
Group Number
Secondary Policyholder Name

First NameLast Name
Secondary Policyholder DOB

MonthDayYear
Is Prior Authorization required for services?
Upload the front of your secondary insurance card

Cancelof
Upload the back of your insurance card

Cancelof
Please select any condition(s) listed below that your child has been formally diagnosed with:

Other
Upload any relevant documentation (previous evaluations, IEP reports, etc.) from the past 6 months.

Cancelof
By signing below,

I give permission for Caring Connections Pediatric Therapy PLLC to contact my insurance carrier to verify my eligibility, benefits, and authorization requirements for therapy services.
Signature
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First Contact Intake Form

Thank you for Reaching Out!

Insurance Verification

Primary Insurance

Secondary Insurance

By signing below,