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Child's Information

Child's Age:
Zip Code / Postal Code:

Parent/Guardian Information

Parent/Guardian First Name:
Parent/Guardian Last Name:

Insurance Information

Insurance Type:
Name of Insurance Provider:
Plan Name:
Insurance Member ID:
Insurance Group ID:
Insurance Member Services Phone Number:

Additional Information

Date of Diagnosis (Example 01/01/2010):
Diagnostic/DSM code:
Diagnostic Clinician:
Diagnostic Clinician's Phone Number:
Medical Primary Care Doctor:
Primary Care Doctor's Phone Number:
What are your primary concerns: