PracticeAxis -

Parent/Guardian Appointment Request Form

Please fill out this form if you are requesting an appointment for your child or for someone else for whom you are a guardian. We will contact you soon with next steps to find a therapist. We look forward to providing therapy services, we do not provide any custody or legal work of any kind. Thank you!

What is your child's first name?*

What is your child's last name?*

Have you already submitted this form for another child, or will you be submitting this form for another child?*

Enter Your Child's Date of Birth in this format: YYYY-MM-DD*

What is Your Child's Age?

Parent/Guardian's First Name*

Parent/Guardian's Last Name*

Child's Custody Status*

Description

What is your email address?*

What is your phone number?*

Preferred Method of Contact

Please Select Your Insurance Provider?*

Policy Holder Name

Policy Holders Date of Birth

Please Enter the Insurance Member ID:*

Insurance Group Number

Please enter the mental health provider number from the back of your insurance card:

Insurance Coverage Start Date

Insurance Coverage End Date

If your insurance is covered through your work, please list your employer below

Street Address (This is used to verify insurance eligibility.)*

City*

State*

Zip Code*

Which type of therapy are you seeking for your child?*

Please describe in your own words your reason for seeking therapy for your child:*

Preferred Appt Time*

Preferred Appointment Days*

Monday

Tuesday

Wednesday

Thursday

Friday

Are you open to telehealth?

Yes

No

Okay to send a survey?*

yes

no

Please verify your request*