ABOUT Date of first contact: New Patient Registration Patient Name Age Gender Idenitifed as Sex Parent/Guardian Name Phone Number Is it okay to leave a voicemail: Yes No Is it okay to utilize mail correspondence: Yes No Address City/State/Zip code: Service Individual Group Family Couples Autism Assessment ADHD Assessment IEP Assistance Sleep training Birth work lactation Other How Do You Want To Perform Session In person sessions Telehealth sessions Presenting Issues Currently take medication Yes No Select Date Select Time How did you hear about us Insurance Information Name of Primary Subscriber DOB of Primary Subscriber Insurance Name/Type Member ID Group# Customer Service phone number on back of card: Initial appt scheduled for Left message to schedule (Date/Time) Left message to schedule (Date/Time) Insurance Verification Date of verification Copay (yes, no, if yes how much is the copay) Policy effective date Member responsible for Insurance responsible for Is Telehealth covered Is there a deductible (yes, no, if yes what is the deductible) Is there a visit limitation (if yes what is the number) Is there an initial pre-athorization needed (yes or no) Is there a follow up preauthorization needed (yes or no) IF PREAUTHORIZATION NEEDED FIND OUT HOW TO GO ABOUT GETTING IT Authorization Number with dates Number of sessions authorized Send claims to Electronic submission payer id Reference#/Representative Name SUBMIT
