Adult Services Inquiry Form

Do you have Colorado Medicare? *

Yes No
Do you have Colorado Medicaid? *

Yes No
Please be advised that STAR Institute is currently in the process of becoming a Colorado Medicaid provider. We currently have a Medicaid waitlist that we will refer to when we begin to see Medicaid clients. Would you like to be added to our waitlist? *

Yes No
Please upload a clear photo of the front and back of your Medicaid card. *

Browse Files

Cancel of
Billing Insurance? *

Yes No
Name of Primary Insured: *
Primary Insured's Date of Birth: *

Month Day Year
Date
Primary Insured's Phone #:

Area Code Phone Number
Primary Insured's Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Insured's Employer
Name of Insurance Company *
Member ID *
Group Number *
Provider Insurance Phone #:

Area Code Phone Number
Claims Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

How did you hear about STAR Institute? *
If you selected "other" please describe:
If you were referred, who referred you to STAR Institute?

Pediatrician/Family Physician Occupational Therapist School/Educator Family member/Friend Therapist/Psychiatrist
Name of person who referred you

First Name Last Name
Referral address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Does STAR Institute have your permission to send a thank you?

Yes No

	Minor Impact	Low Impact	Moderate Impact	High Impact	Severe Impact	Comments:
Activities and daily living (e.g. dressing, bathing, feeding myself, toileting, intimacy)
Instrumental activities of daily living (e.g. transportation - driving/public transport, home maintenance/cleaning, shopping, meal preparation, money management)
Health management (e.g. scheduling appointments, obtaining/taking medications, tolerating appointments)
Rest and sleep
Education
Work
Parenting
Leisure (e.g. participating in interests/hobbies)
Social participation (e.g. lunch with friends, holiday events, community events)

How can we contact you?