Child New Patient Appointment Request

Child New Patient Appointment Request
Please fill in this form in order to request an appointment with our office. Mandatory fields are marked with an asterisk (*).
Contact Information
Parent's Name*

First NameLast Name
Parent's Email*

Confirmation Email
Child's Name*

First NameLast Name
Child's Gender*

MaleFemale
Child's Date of Birth*

MonthDayYear
Date
Is your child under the age of 19?*

Yes, my child is under the age of 19No, my child is age 19 years or older
IMPORTANT NOTE: We are only scheduling clients below the age of 18 years 11months. By typing "I understand" you are acknowledging you have read this statement and that if your child is not in this age bracket with corresponding visit reason, you will not be contacted back by our office to schedule. *
Reason for Visit- NOW/COMP waiver, Renewal of existing Katie Beckett, and Re-evals strictly to continue ABA services (these 3 visit reasons ONLY are all ages).*
Has your child been previously diagnosed with Autism Spectrum Disorder?*

Yes, my child has a previous ASD diagnosisNo, my child has never had an ASD diagnosis
Please select your child's language level below.*

Single wordsPhrase Speech (putting 3-4 words together)Full Sentences (speech that contains multiple clauses)Completely Non-Verbal
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number (if applicable)

Area CodePhone Number
Primary Insurance Carrier *Please note: We DO NOT accept Amerigroup Medicaid*
Insurance Prefix and ID Number:*
Insurance Group Number (if applicable):
Number on back of insurance card for provider services:*
Name of primary insured (if applicable):*
Date of Birth of primary insured (if applicable):*

MonthDayYear
Date
Secondary Insurance Carrier
If other, please list other insurance:
Secondary Insurance ID Number:
Secondary Insurance Group Number (if applicable):
Appointment Preferences
Requested Provider:*
Referring Provider (if applicable):
Referring Provider Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring Provider Phone Number (if applicable)

Area CodePhone Number
Referring Provider Fax Number (if applicable)

Area CodePhone Number
Notes from referring provider: (optional)
PLEASE BE ADVISED:

Our office will give you a call to schedule in 2-4 business days to bring your child in for our next available intake appointment with one of our providers.

We bring clients in for the initial intake first, then we would schedule any necessary comprehensive testing once the session has ended.

We ask that you please do not contact the office to check the status of this appointment request unless it has been longer than 4 business days past your submission date.
IMPORTANT: Please acknowledge you have read the message below and understand this information by typing "yes" or "acknowledged"*
Should be Empty:

Child New Patient Appointment Request

Contact Information

Appointment Preferences