New Patient Information for 17 & Under

1Patient Form
2HIPPA Confidentiality Form
3Primary Doctor Information
4Insurance Co. Information
5Therapy Patients’ Bill of Rights
6Burns Inventory Checklist for Children
7ADHD Self-Report Scale Symptom Checklist
8Telemedicine Informed Consent Form
DD slash MM slash YYYY
Home Address:
Authorize electronic communication:
Preferred method of appointment reminders:
Sex:
MM slash DD slash YYYY
Are you currently in treatment anywhere else?

To avoid being charged $80.00, a 24 hour notice is required for all cancelled/missed appointments. You are responsible for notifying the office of all name, address, phone number and insurance changes as soon as possible to avoid a claim being denied. Please understand that you are ultimately responsible for all fees incurred in the event that the insurance carrier does not pay. Returned checks will result in a $30.00 charged fee. All fees not paid within 90 days will be sent to a collection agency, and a 35% processing fee will be added to your account. Statements will be sent out periodically. For patients ages 17 and younger, the parent or guardian who signed these forms is responsible for any outstanding balance.