Forms & Questionnaires old

Please complete ALL paperwork listed below and upload clear pictures of the front and back of your insurance card(s). Click here [link to insurance and billing] for more information on insurance and billing.

Once we have received all necessary documents, our clinical team will review your paperwork and we will be in touch within 1-2 weeks to let you know the next steps and timeline.

PERSONAL INFORMATION FORM

AUTHORIZATION FOR THE EXCHANGE OF INFORMATION

CONSENT/HIPAA FORM

Please complete the most applicable ONE of the following questionnaires:

PARENT QUESTIONNAIRE: For children under the age of 18 or still enrolled in high school.

ADULT QUESTIONNAIRE: For individuals 18 and over (and not a high school student)

CUESTIONARIO PARA LOS PADRES: Si es padre(s) de un niño menor de 18 años, complete el cuestionario para padres por favor.

INSURANCE CARD:

Please upload clear pictures of the FRONT & BACK of the client’s insurance card(s).

 

(Put the upload link here)

 

 

ADDITIONAL FORMS AND DOCUMENTS:

 

Please upload scanned copies of other important documents to be included in your comprehensive review and consultation (e.g., IEP, 504 Plan, previous psych testing, hospital discharge summaries, etc.). Each document must be a single file- please do not upload large documents one page at a time.

 

(put upload link here)

 

TEACHER INFORMATION FORM: This form is especially helpful for questions regarding academics and learning disabilities.

 

PRIOR TO YOUR CONSULTATION APPOINTMENT:

 

VISION & HEARING SCREENING: Please have the client’s vision and hearing screened by their medical provider.

 

NEUROLOGICAL ISSUES: If either you or your child has had any neurological injuries that have been treated, please have your medical provider clear you for testing, and provide us with any reports summarizing the injury and treatment.

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