Are you interested in therapy, assessment, or both?*
Are there current concerns related to:
Have there been any recent changes in:
Do you have any dietary or feeding concerns?*
Any access to weapons in the home?*
Any prenatal difficulty?*
Any delays in development?*
Do you have any history of the following medical concerns?
Do you have any history of:
Would you like us to see if we can bill your insurance?*
While we will do our best to bill your insurance, it is your responsibility to contact your insurance company for information regarding any deductables or copays. If we cannot bill your insurance or your session fees go to your deductable, you will be responsible for the cost of service at the time of the appointment.
Please make sure you inform us of any secondary coverage prior to your first appointment.
Superbills for the cost of service can be provided following payment for each session.
Please upload the front and back of your insurance card
Thank you for completing this form.
We will reach out to you within 48 hours to discuss scheduling!
