STAR Institute New Client Inquiry Form

New Client Inquiry Form
Client Preferred Name:*

First NameLast Name
Legal Name (if different than preferred)?
(Only required for insurance purposes)
E-mail:*
Access to our portal will be emailed to this address
Client Date of Birth:*

MonthDayYear
Current Age (in years): *
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Mobile Number:*
**If International please insert full number in the section titled "Briefly Describe the Concerns**
Referral Source: *
If no provider, how did you hear about us?
International Phone Number and/or Zip Code
Are you local to Colorado?*

YesNo
Do you have Medicare?*

YesNo
Do you have Colorado Medicaid?*

YesNo
Gender*

MaleFemaleNon-binaryOther/Undefined
Legal Sex (for insurance purposes ONLY)*

MaleFemaleIntersexOther
Pronouns?

She/HerHe/HimShe/TheyHe/ TheyThey/ThemOther/Prefer not to answer
Racial/Ethnic Identity:
Primary Concern(s):*

SensorySocial/EmotionalSpeech / AuditoryMental HealthFeeding/Dietary*Three or more
Completed By:*
Name (if completed by anyone other than self):
Relationship to Client:
Please send me appointment reminders via:

Text Message (message and data rates may apply)Phone CallEmailNone of the above
Should be Empty: