PERSONAL DEMOGRAPHICS AND INSURANCE FORMBrain …



right01115 ELKTON DR, STE 301, COLORADO SPRINGS; 6000 EAST EVANS AVE, BLDG 1, STE 350, DENVER 80222; 719-357-6471001115 ELKTON DR, STE 301, COLORADO SPRINGS; 6000 EAST EVANS AVE, BLDG 1, STE 350, DENVER 80222; 719-357-6471FAX:719-434-9811*Required *SCHEDULE IN (Colorado Springs or Denver): FORMTEXT ?????*CLIENT NAME: (Include legal name if different than the name you currently use): FORMTEXT ?????*Gender: FORMTEXT ?????Language Client speaks:If other than English, do they understand English:*Client’s DOB: FORMTEXT ?????*Client’s phone number: FORMTEXT ?????*Client’s Email: FORMTEXT ?????Please Fill in all Most Appropriate Information:*Biological Parent: _________________________________________*Phone number: FORMTEXT ?????*Bio parent Email: ___________________________________________*Foster Parent: ______________________________________________*Phone number: FORMTEXT ?????*Foster parent Email: ________________________________________*Guardian ad Litem (GAL): ________________________________________*Phone number: FORMTEXT ?????*GAL Email: _____________________________________________*Case worker: _____________________________________________ *Phone number: *Does client experience any of the following:?Legal Blindness?Limited Mobility?Nonverbal or ? Limited Verbal Skills (can’t speak in 3-4 word phrases)?Not fluent in the English language*School Grade (ONLY if 18 yrs or under): FORMTEXT ?????*Home Address (please include zip code): ____________________________________________________________________________________________________________________________________________________________________WHO DO WE CALL TO SCHEDULE*Name:*Relationship to Client:*Phone Number: *Please list name of Primary Insurance: FORMTEXT ?????*Policy Holder Name: FORMTEXT ?????*Policy Holder DOB: FORMTEXT ?????*Insurance#/Policy #(s)/Medicaid Member ID#/Tricare SS: FORMTEXT ?????*Group # (if applicable-only for some 3rd party payers): FORMTEXT ?????.*If Tricare – Tricare Benefits # on back of military ID- needed for insurance verification: FORMTEXT ?????*Is Tricare policy holder active duty: FORMTEXT ?????*Any other Insurances (if yes, please list): FORMTEXT ?????*Who you were referred by:SELFDR/THERAPISTFRIENDINTERNET*If referred by A Doctor or Therapist or another medical professional (name and contact information):Are you currently in services with this provider (pls note what type and for how long)? FORMTEXT ?????*Is this testing Court Ordered ? YES ? NO*Please note, use of non-prescribed psychoactive drugs may lead to testing results that donot accurately portray the person’s true level of functioning. Thus, we ask that the personscheduled for an evaluation refrain from using non-prescribed psychoactive drugs at leasttwo weeks prior to the evaluation.*Type of assessment you are requesting: (all testing starts at age 6 except autism and the Adaptive/IQ –(IF UNSURE DON’T MARK ANY – we will review and let you know based off of History and information provided)? Psych/Mental health assessment? Adult Neuro Psych (includes psych testing)? Child Neuro Psych (includes psych testing)? Disability Neuro Psych (applying for SSI or Disability)? Autism Testing (includes developmental delays, adaptive/iq)? Adaptive/IQ (Note: Adaptive functioning evaluations (Vineland +/- SRS-2) always include a cognitive assessment as standard practice. This evaluation cannot be altered)? Learning Disorder Testing ................
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