Intake Forms and Questionnaires

Prior to your first appointment, please complete the following forms:

INTAKE FORMS

Personal Information & Insurance Form: This is an electronic form gathering basic personal information.

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

HIPAA Form: This form requires your electronic signature

Outpatient Service Contract: This form requires your electronic signature

Informed Consent for Telehealth Services: This form requires your electronic signature

Consent to Treat: This form requires your signature

CLIENT QUESTIONNAIRES

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

PRIOR TO YOUR INTAKE ASSESSMENT APPOINTMENT

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 clicking here.

  • 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.
Scroll to Top