Patient Forms

Online Intake Forms

Complete your new patient paperwork online before your first visit. All information is transmitted securely and kept strictly confidential in accordance with HIPAA regulations.

Patient Information

Patient First Name*

Patient Last Name*

Date of Birth*

Gender

Parent/Guardian Information

Parent/Guardian First Name*

Parent/Guardian Last Name*

Relationship to Patient*

Phone Number*

Email Address*

Street Address*

City*

State*

ZIP Code*

Emergency Contact

Name*

Phone*

Relationship*

Insurance Information (for Superbill Purposes)

We are a private pay practice. If you would like us to provide a superbill for out-of-network insurance reimbursement, please provide your insurance details below.

Insurance Provider

Policy Number

Group Number

Policy Holder Name

Policy Holder DOB

Referral & Primary Concerns

How did you hear about us?

Referred by (name, if applicable)

Primary concerns or reasons for seeking therapy*

What are your goals for therapy?

Medical & School Information

Current Medications

Allergies

Has the patient been in therapy before?

School Name

Current Grade

Does the patient have an IEP or 504 Plan?

Any additional information you'd like us to know

All information is encrypted and transmitted securely. Your data is protected in accordance with HIPAA privacy regulations.