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Arcadia In-School Therapy Intake Form
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* Indicates required question
Email
*
Your email
Name of student:
*
Your answer
Name of parent/guardian:
*
Your answer
Student date of birth:
*
MM
/
DD
/
YYYY
Email address of parent/guardian
*
Your answer
Phone number of parent/guardian:
*
Your answer
Address of student:
*
Your answer
What kind of insurance policy does the student have?
*
Commercial insurance (private)
Medical assistance
Medicare
Private Pay
Other
Who is your primary insurance carrier (e.g. BCBS, Health Partners, etc)?
Your answer
Group Number:
Your answer
Individual ID Number (PMI# for UCare)
Your answer
Name of the policy holder:
Your answer
Relationship to the policy holder:
Your answer
Policy holder DOB:
MM
/
DD
/
YYYY
Policy holder address:
Your answer
Secondary insurance:
Your answer
Any other information for us?
Your answer
Do we have your permission to talk to Arcadia about your child's involvement in therapy? (No personal information will be shared without a written release of information)
*
Yes
No
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