New Patient Information Ages 17 & Under

17 & Under

"*" indicates required fields

1Patient Information Form
2HIPPA Confidentiality Form
3Primary Core Doctor Information Release Form
4Insurance Information Release Form
5Therapy Patients’ Bill of Rights
6Burns Inventory Checklist for Children
7ADHD Self-Report Scale Symptom Checklist
8Telemedicine Informed Consent Form
MM slash DD slash YYYY
Home Address:*
Authorize electronic communication:
Preferred method of appointment reminders:
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 an additional $30.00 fee. Within 90 days, any unpaid fees 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.