Child’s Information

Child’s Age:
Zip Code / Postal Code:

Parent/Guardian Information

Parent/Guardian First Name:
Parent/Guardian Last Name:

Insurance Information

Policy Holder’s First Name:
Policy Holder’s Last Name:
Insurance Type:
Name of Insurance Provider:
Plan Name:
Insurance Member ID:
Insurance Group ID:
Insurance Member Services Phone Number:

Additional Information

Date of Diagnosis (Example 01/01/2010):
Diagnostic/DSM code:
Diagnostic Clinician:
Diagnostic Clinician’s Phone Number:
Medical Primary Care Doctor:
Primary Care Doctor’s Phone Number:
Services Desired (Select all that apply):

What are your primary concerns: