Avenues for Autism | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Sex at birth

For insurance verification

Gender

Full Address (Street, City, State, Zip)

Limited to 600 characters

Is the client under legal guardianship?

Please note: Due to HIPAA regulations, appointment requests can only be made by the individual seeking services or their legal guardian.

Yes No

Administrative

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Insurance Company

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Is there anything that the practitioner needs to know?

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

Limited to 600 characters

Reason for care

What brings you to therapy at this time?

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.