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!
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Email *
Form Completion Date: *
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Child's Name and Parent/Guardian Name *
Child's Date of Birth *
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Contact Phone Number and Mailing Address *
Did someone refer you to Mealtime Connection? If so, please provide the name of the person or place below. *
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
What is your child's birth history? *
What was your child's primary diagnosis prior to coming to Mealtime Connection? *
What is your child's past medical history? (Include any other pertinent information in this section)
Areas of Concern; Please select all that apply *
Required
Please use this space to describe in greater detail the concern(s) selected above:
What are your overall goals for your child to achieve?
What day of the week and/or time frame would be most convenient for your child's evaluation and on-going therapy? i.e. Monday between 8:00am and 10:00am *
Please click "Next" below to continue to the Voluntary Consent & Waiver Form
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