Whole Child Therapy | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Please provide your insurance plan name and, if known, your deductible, copay/coinsurance, and annual speech therapy visit limit.

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Have we been sent a referral/authorization?

Please indicate which ones and from whom?

Limited to 600 characters

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Availability and preference

Please elaborate on scheduling needs if you or your child's schedule is restricted.

Limited to 600 characters

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.