Child's Name
*
Parent/Guardian Name
*
Relationship to the Child
*
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Parent
Guardian
Other
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Phone
*
Email
*
To receive OT therapy from La Plata Family therapy it is important that you have received a referral from your Primary Care Provider. Do you have a referral for OT from your Primary Care Provider?
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Yes, I have a referral
No, I do not have a referral
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Primary Care Provider Name
Primary Care Provider Phone Number
How would you like to receive services?
*
In-Person Only
Telehealth Only
Open to Both
What Is the Best Way To Contact You?
*
Phone
Email
Text Message
Would you like to receive our newsletter?
*
Yes
No
How Did You Hear About Us?
*
Please briefly describe the issue(s) you would like to work on so that we can find the most appropriate therapist.
*
Insurance Verification (if you plan to utilize your insurance)
Do you plan to utilize your insurance?
*
Yes
No
*If you do not plan to utilize your insurance you may skip the rest of the questions and submit your form!
Since OT is different than other kinds of therapy, it is important that you verify if your insurance covers OT. Have you verified if your insurance covers OT?
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Yes, I have verified that OT is covered by my insurance provider
No, I have not verified that OT is covered by my insurance provider
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Name of Policy Holder
Address of Policy Holder
Postal code
Name of Insurance Provider
Member ID
Group ID
Email & Text Message Acknowledgement & Use Consent
I understand that the use of email and SMS text messaging is inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to La Plata Family Therapy therapists and/or office staff communicating with me via email or text message.
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