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Client Information
Please answer the following questions. Our Client Care Coordinator will be in touch very soon to talk to you more about scheduling your first appointment.
Please tell us how you heard about us *
If you heard about us from a source other than those listed above, how did you hear about us?
First Name *
Last Name *
Name of parent or guardian if applicable
Mailing address *
City *
State *
Zip Code *
Email
May we send you emails?
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Gender *
Social Security Number *
Date of Birth *
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Age Group *
Phone Number *
What is the best time(s) of day to contact you for scheduling? *
May we send you text messages? *
School Attended (if client is a minor)
If you will be using insurance, what type(s) of insurance do you have? *
If you have private insurance, Medicaid, or Medicare, what is your member ID?
If you have private insurance, what is your group number?
If you are scheduling a minor, what name is the child insured under? (Typically a parent or guardian)
If you are scheduling a minor, what is the insured's date of birth?
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Is there a particular provider you are requesting? *
What services are you seeking? *
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What are the primary concerns that you are seeking services for? *
Is there anything else we should know before scheduling your first appointment?
Thank you for contacting us. Our Client Care Coordinator will reach out to you shortly to answer any additional questions you may have as well as to assist you in getting your initial appointment set up.
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