REFER A PATIENT

Please fill out the intake form below and submit the available supporting documentation.

Nurse Checking Girl

Client Intake Form

Referring Physician Information

Client's Information

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Parent/Guardian Contact Information

Insurance Information

Supporting Documentation Checklist

Please checkmark the documents submitted below.
Letter of Necessity
Diagnosis/Neurological Assessment
Individualized Educational Plan...
Physician Assessment...

Thank you for thinking of us for your patient's behavioral needs. 

One of our team members will be in contact with the client's guardian to arrange a consultation.