Safe & Sound Protocol - New Client
Today's Date:
-
Month
-
Day
Year
Date
Client Name
*
First Name
Last Name
Client Age:
*
Client Date of Birth:
*
-
Month
-
Day
Year
Date
Client Phone Number
*
-
Area Code
Phone Number
Best Day and Time to Call:
Client Email:
example@example.com
Parent or Emergency Contact:
First Name
Last Name
Relationship to Client
Parent/Contact Phone Number
-
Area Code
Phone Number
Parent/Contact Email
example@example.com
Insurance:
Blue Cross Blue Shield PPO
Out of Network
Lyra
Not using insurance
Please share your concerns or reasons you are interested in SSP?
Anxiety
Attention Difficulties
Behavior and emotional regulation
Trauma
Sound or other sensitivity
Health condition
Other
Availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning 9-12
Afternoon 12-3pm
Late afternoon 3pm- 5pm
Evening 5pm-8pm
Due to Covid-19 please let us know the type of session you prefer?
*
Prefer In-Office only
Prefer Online only
Open to either
Please share how you found us:
Website
Internet Search
Physician Referral
School Referral
Friend
Other Provider
Psychology Today
Other
Name of person who referred you to us:
Name of who referred you
Other information to Share:
Completed by:
*
First Name
Last Name
Submit
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