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

If the client is an adult, is the client under legal guardianship?

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

Yes No Not applicable - the client is a minor

If the client is under legal guardianship, please identify the legal guardian's name, date of birth, and contact information.

Limited to 600 characters

Administrative

Referral source

How did you hear about our services?

Driver's license upload

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

Billing & Payment

Insurance Company

Please write the name of your insurance company. If you do not have insurance and will be privately paying for services, write "self-pay".

Insurance card upload

Upload a photo of your insurance card

Who is the primary insured on the insurance plan?

Me Someone else

If the primary insured is someone else, please list their name, date of birth, and address.

Limited to 600 characters

Reason for care

What brings you to therapy at this time?

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

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.