Group Intake Form

—-

    Child's Information

    Parent/Guardian Information

    Contact Information

    Emergency Contact Name and Number in case we cannot reach parent:

    Social Group Information


    Behavior Information

    Help us learn more about your child. We have designed the following questions so we can best prepare for our groups and anticipate the children’s needs.

    INSURANCE REIMBURSEMENT FROM YOUR PPO

    Please note that pediatric group speech/language services are often not covered by insurance plans. Will you need a statement for insurance to try for reimbursement of services?*

    If yes, what insurance carrier provides your medical coverage? This question is informational only to help us determine appropriate codes to include on your superbill. We do not handle claim submission or phone calls to your insurance company.*