IDENTIFIED CLIENT DEMOGRAPHIC INFORMATION
*If your PRIMARY insurance is an HMO plan you will need to obtain a REFERRAL from your primary care provider for SPIN PRIOR to your first appointment with us. If you do not have the referral from your primary care provider your appointment will be cancelled.
BIOLOGICAL FAMILY INFORMATION
If the client’s biological parent(s) and/or court appointment legal guardian(s) is not present at the time of the appointment the appointment will need to be cancelled and rescheduled. All legal custody/guardianship paperwork must be sent prior to the scheduled appointment via fax or mail.
(Must bring proof of custody if living with person(s) other than biological Parent(s).) Proof must state that the person providing treatment consent and attending appointments has LEGAL rights of the child.)
Has the client ever received Behavioral Health Services elsewhere?