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Request an Appointment for Your Child

Please complete this form to request an appointment for your child.

Date

YYYY

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Email

Parent/Guardian Phone

(###)

###

####

Child/Dependent Name

First Name

Last Name

Child/Dependent Date of Birth

YYYY

Do you have a preferred therapist?

Briefly, what is bringing you in to therapy?

Preferred Location

Will you be having us submit claims to your insurance?

If so, who is your insurance carrier?

Please understand that while we verify that your insurance is active, it is your responsibility as the insurance policy holder to know the benefits of the plan you carry. The best way to confirm any benefit is to call your insurance company and ask what your mental health benefits are and who is in your network.

Yes, I understand.

No, I don't get it.

Primary Insurance Policy Number

Do you have a SECONDARY Insurance plan?

Yes

If yes, please include the Insurance Company Name, Policy number, Policy Holders Name and Birthdate here.

Schedule

Tell us a little bit about your schedule. It's important for us to know that your schedule and our availability is compatible and will provide consistency for you.

Are you utilizing EAP benefits?

This must be declared at the time of scheduling because we do not participate in all EAP programs.

Yes

EAP Authorization Number & Company

Referral Source

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