Packet for patients five years of age and older - Atlantic Health System

APPOINTMENT INTAKE FORM
***Please complete entire form (2 pages) before submission***
Today’s Date __________________
Referred by: ___________________________
Patient’s Name ____________________________________
Mother’s Name ___________________________________
Father’s Name ____________________________________
Patient’s DOB _______________
Mother’s DOB _______________
Father’s DOB ________________
Home #________________Wk # (Father/Mother) ______________________Cell #____________________
Home Address___________________________________________________________________________
City______________________State______County_______________________Zip Code_______________
Pediatrician’s Name, address, telephone no.
_______________________________________________________________________________________
PRIMARY INSURANCE: Name & ID No. __________________________________________________
Name of Subscriber: __________________ Insurance Co. Address _________________________________
Relationship of subscriber to insured ______________ Subscriber Date of Birth ____________________
(*Please provide copy of both sides of ALL insurance ID cards)
SECONDARY INSURANCE: Name & ID No. _________________________________________________
Name of Subscriber: __________________ Insurance Co. Address _________________________________
Relationship of subscriber to insured ______________
Subscriber Date of Birth ____________________
Has your child or child’s sibling previously been evaluated here at the Child Development Center?
Yes _____ No _____ If yes, please provide date and explain ____________________________
_____________________________________________________________________________________
Are you concerned about autism?
Yes _____ No _____ If yes, please explain ___________________________________________
_____________________________________________________________________________________
Has your child been formally evaluated/tested by the school Child Study Team? Yes _____
No _____
If yes, Date of evaluation and/or test _____________________
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