Intake Forms and Questionnaires

If we are in-network with your insurance or you are planning to pay out-of-pocket, please complete ALL intake paperwork here and upload or email clear pictures of the front and back of your insurance card(s). Once received, we will email you a welcome letter and link to our patient portal. If you believe you have submitted everything and have not heard from us, please email our admin staff HERE. (Please check to make sure ALL paperwork was submitted and allow one week for processing before contacting us. Thank you!)

Personal Information/Referral Form: This is an electronic form gathering basic personal information.

Authorization for the Exchange of Information: This form requires information on other providers.

Multiple Consents/HIPAA Form: This form requires a date and signature.

Please complete ONLY the most applicable ONE of the following Questionnaires

(We understand that you may not be able to recall all information listed. Please do the absolute best you can):

Parent Questionnaire: If you are the parent(s) of a child under the age of 18, please complete the parent questionnaire

Adult Questionnaire: If you are over 18 (and not a high school student) please complete the adult questionnaire

Cuestionario para los Padres: Si es padre (s) de un niño menor de 18 años, complete el cuestionario para padres

Teacher Information Form

Please Upload Clear Pictures of the Client’s Insurance Card(s) and Other Important Documents Below:

Please Upload Clear Pictures of the FRONT & BACK of the Client’s Insurance Card(s) and Scanned Copies of Other Important Documents (each document MUST be a single file. PLEASE DO NOT UPLOAD LARGE DOCUMENTS ONE PAGE AT A TIME (e.g., IEP/504 Plan, previous psych testing, hospital discharge summaries, etc.).

Click or drag files to this area to upload. You can upload up to 15 files.

Prior to your intake appointment please provide:

Medical Screening: If possible, please have the client’s vision and hearing screened by their doctor prior to their intake appointment.

Documents: Please bring copies, not originals, of the following items (we will need to keep them, and you will likely want to have the originals). We are not able to make copies in our office of more than 5 pages of client documents. If you’d prefer to upload the documents do so by using the upload form provided at the bottom of the page.

  • A photograph of your child
  • Past evaluations of your child (school, or private) where appropriate
  • Any discharge summaries from past hospitalizations or partial hospitalizations.
  • Copies of any IEPS or 504 Plans from the past two years, if appropriate
  • 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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