We are dedicated to providing exceptional care and support for children and their families. To help us better understand your needs and ensure a seamless experience, please complete the form below. This information will allow us to evaluate and facilitate services tailored to your child’s unique requirements. Rest assured, all information provided will be handled with the utmost confidentiality and in accordance with our Privacy Policy. If you have any questions or need assistance, feel free to contact our office at 404-709-0840. Thank you for trusting us with your child’s care!

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Person Completing the Form

Name *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

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Zip Code

Relationship to Client *

Permission/Authorization: *

• I confirm that I am authorized to provide this information on behalf of the client.

Client Information

Client's Full Name *

Date of Birth: *

Age *

Sex *SexMaleFemale

Phone *

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Primary Language *

Other Languages Spoken in the Home *

Referred By *Referred ByPhysician/DoctorPediatricianTherapistSchoolPrevious Client/Family MemberInsurance CompanyWebsite/Social MediaCommunity ProgramHospital/Medical FacilityOther Medical ProfessionalOnline SearchFamily Advocate or Social WorkerFriend or Family MemberOther

Referral Name *

Reason for Referral *

Physician Information

Client’s Physician Name *

Client’s Physician Telephone Number *

Please indicate your primary concerns in relation to the client:

Primary Diagnosis *

Service(s) requested *

Primary Insurance Information

Person Responsible for Account *

Relationship to Client *

Date of Birth: *

Subscriber I.D. #: *

Insurance Company: *

Policy Effective Date: *

Group #: *

Do you have a Secondary Insurance?

• Yes
• No

Secondary Insurance Information

Person Responsible for Account *

Relationship to Client *

Date of Birth: *

Subscriber I.D. # *

Insurance Company *

Policy Effective Date *

Group # *

Please upload your insurance card

Click or drag files to this area to upload. You can upload up to 3 files.

Please upload your child’s hearing test/newborn hearing screening (if 3 or under)

Click or drag files to this area to upload. You can upload up to 3 files.

Please upload the child’s Rx from doctor

Click or drag files to this area to upload. You can upload up to 3 files.

Comments/Additional Notes:

Agreement and Consent *

• I confirm that all information provided in this form is accurate and complete to the best of my knowledge. I understand and agree that the information provided will be used for the purpose of evaluating and facilitating services for the client. I consent to the collection, use, and storage of the provided information in accordance with the Privacy Policy and Terms of Service. I also authorize Georgia Pediatric Therapy to contact me regarding this form and related services.

HIPPA Consent *

• By checking this box, I agree to communication regarding my child's care, such as appointment scheduling and reminders, to be sent via phone call, text message, or email. Learn more about HIPAA Consent

Signature *

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