Parent / Guardian Information

Your First & Last Name (required)

Your Date of Birth

Your Address

Your Email (required)

Your Phone Number (required)

Client / Dependent Information

Client's First & Last Name (required)

Client's Date of Birth (required)

Client's Address (if different)

Client's Primary Diagnosis (required)

Date of Diagnosis

Secondary Diagnosis

Client's Primary Care Physician (required)

Address of Primary Care Physician

Phone Number of Primary Care Physician

Referring Provider

Address of Referring Provider

Phone Number of Referring Provider

Insurance Information

Insurance Company (required)

Member's Name (required)

Member's Place of Employment

Address of Member's Employer

Member's Address (if different from above)

Member's Phone (if different from above)

Member's Date of Birth (required)

Note: If you will be receiving insurance information that you have not yet obtained, please input "none" into the following 4 insurance questions.

Insurance ID # (required)

Insurance Group Number

Insurance Phone Number (on back of card)

Insurance Address (on back of card)

Secondary Insurance Information (if applicable)

Insurance Company

Member's Name

Member's Date of Birth

Insurance ID #

Insurance Group Number

Insurance Phone Number (on back of card)

Insurance Address

Current Concerns

Diagnosis

Does the client use aggression towards self or others to communicate?

YesNo

Please explain how client manages social structures

Do you have any final questions for me?

What is the best way to contact you?

PhoneEmail

Final Step

By checking this box, you are digitally signing this form and agreeing to our privacy policy. You confirm that you are voluntarily submitting accurate information so that S^D Associates may research options for you and the client based on the data you've provided. You also give S^D Associates permission to share this information internally with other staff if deemed necessary.

I Agree

Please leave this field empty.