New Client Registration
Please complete and submit this form to begin the intake process for therapy. After receiving this form, we will be contacting you to answer questions and schedule your first appointment. We look forward to meeting your child!
Email address *
Form Completion Date: *
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Client Information
Child's Name *
Your answer
Parent/Guardian Name *
Your answer
Child's Date of Birth *
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Child's Age (i.e. Newborn, 5 Months, 3 Years) *
Your answer
Contact Phone Number *
Your answer
Contact Email (If different from above; Otherwise N/A) *
Your answer
Mailing Address *
Your answer
Did someone refer you to Mealtime Connection? If so, please provide the name of the person or place below. *
Your answer
We are a private pay clinic. We are not in network with any insurance company, including medicaid. We will provide a monthly statement for your records that contain procedure and diagnostic codes upon request. It is the parent/guardian's responsibility to contact the insurance company to find out if out of network coverage is provided. If out of network coverage is provided, it will be the parent/guardian's responsibility to submit monthly receipts (provided by Mealtime Connection) to his/her insurance and to seek reimbursement for therapy directly. Mealtime Connection does not accept payments from insurance companies. (Both boxes must be checked prior to any therapy appointment) *
Required
Medical History & Area of Concern
What is your child's birth history? *
Your answer
What was your child's primary diagnosis prior to coming to Mealtime Connection? *
Your answer
What is your child's past medical history? (Include any other pertinent information in this section)
Your answer
Areas of Concern; Please select all that apply *
Required
Please use this space to describe in greater detail the concern(s) selected above:
Your answer
What are your overall goals for your child to achieve?
Your answer
Scheduling Preferences
What day of the week and/or time frame would be most convenient for your child's initial evaluation/consultation? i.e. Monday between 8:00am and 10:00am *
Your answer
What day of the week and time frame would be most convenient for on-going therapy? Please include a primary and secondary option. *
Your answer
Thank You!
You have completed your Mealtime Connection registration form. We will be in touch with you to discuss your answers and schedule an appointment within one business day!
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