Currently we are only accepting new patients looking for testing/evaluation services.
This form is required for all new and established patients. If you have any questions/concerns about why this information is needed or how it will be used, please email admin@peachpsychology.com
What services are you needing?
Psychological testing
Psychoeducational testing
Katie Beckett Deeming Waiver/NOW COMP evaluation
Therapy
I don't know
Other
Unfortunately, we are not currently taking new patients for therapy. Please check www.psychologytoday.com to search for providers that may be a good option for you. You are also welcome to call our office at 404-796-7777 with any questions.
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This form is easier to complete on laptop or desktop. We also recommend using Chrome (and avoiding Safari!). You may need to upload your insurance card. This form will expand based on your selections.We look forward to working with you!
Are you a returning patient to Peachtree Pediatric Psychology?
Yes
No, I am a new patient
No, but I was a patient of Dr. Cohen's at Georgia Pediatric Psychology
Child's/Patient's Name
*
First Name
Last Name
Child's/Patient's Date of Birth
*
Month, Day, and Year
Child's/Patient's Gender
*
Female
Male
Other
Child's/Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Cell
Home
Work
Other
Alternate Phone Number
-
Area Code
Phone Number
Cell
Home
Work
Other
Best Time to Contact You:
Morning (8:30-12)
Afternoon (12-4)
Early evening (4-6)
Email
*
example@example.com
Referring provider (name and organization)
Dr. Jane with Jane Pediatrics
Reason for referral:
*
Autism Spectrum Disorder
ADHD
Learning Challenges
Developmental Delays
Gifted
Katie Beckett/Deeming Waiver or NOW/COMP evaluation - please include deadline in Other box if applicable
Other
If other, please describe:
Has your child previously had developmental, psychological, or psychoeducational testing?
*
Yes
No
Primary insurance - please note we are only in network with BCBS, straight Medicaid, and Caresource
*
BCBS
Caresource
Medicaid (SSI or KBDW; NOT in network with Wellcare, Amerigroup, or Peachstate)
Self-Pay (we can provide a superbill)
United Healthcare (OUT OF NETWORK)
Does your child have any other insurance besides Medicaid/Caresource?
Yes - please make sure to provide both your primary insurance, even if we are out of network, in addition to your Medicaid/Caresource information. Failure to do so will result in you being responsible for the cost of all appointments.
No
Insurance ID
*
Insurance Group Number (if applicable)
Number on Back of Insurance Card for Providers
Please upload a picture of the front and back of the insurance card
Browse Files
Cancel
of
Name of Parent who Provides Insurance (if applicable)
First Name
Last Name
Date of Birth of Parent who Provides Insurance (if applicable)
-
Month
-
Day
Year
Date
Address of Parent Who Provides Insurance
same
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have another insurance policy covering your child? Please know that if you do not inform us off all policies covering your child and your claim is denied, you will be responsible for the cost of all services.
*
Yes
No
Secondary Insurance
BCBS
Caresource
Humana (NOT Tricare plans)
Medicaid (SSI or KBDW only - NOT in network with Wellcare, Amerigroup, or Peachstate)
Self-Pay (we can provide a superbill)
United Healthcare (out of network)
Secondary Insurance ID
Secondary Insurance Group Number (if applicable)
Provider Number on Back of Card for Secondary Insurance
Name of Parent Who Provides Secondary Insurance (if applicable)
First Name
Last Name
Date of birth of parent who provides secondary insurance (if applicable)
-
Month
-
Day
Year
Date
Address of parent who provides secondary insurance (if applicable)
same
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Appointment Day/Time (last appointment of the day is 2pm)
Morning
Afternoon
Monday
Tuesday
Wednesday
Thursday
For Provider Only
Name of Person Completing This Form
First Name
Last Name
Relationship of person completing form to patient
Parent/Guardian
Self
Pediatrician
Other provider
Do you have a provider preference?
Next Available
Dr. Avital Cohen
Dr. Asher Lindenbaum
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