New Client Appointment Request 2023

New Client Request Form

*Our Office Is NOT Accepting Any Independent Educational Evaluations.*
Please select a service:*

INDIVIDUAL THERAPYPSYCHOLOGICAL EVALUATIONPRIVATE SCHOOL / GIFTED & TALENTED TESTINGIQ / MENSA TESTINGGIRL GROUP / OTHER
IMPORTANT INFORMATION ABOUT OUR CURRENT THERAPY AVAILABILTY:
- For children, we currently ONLY have availability for 8 year olds and older. We do not offer Play Therapy at this time.
- Most clinicians at our office are in-network with Aetna, BCBS, Cigna and United Healthcare. We do NOT accept Medicaid.
- The estimated cost range for therapy is $85-$200. This depends on insurance contracted rates as well as if you see a therapist or a psychologist.
- Therapy spots are LIMITED at this time. Majority of our current availability is for during the day. We may no longer have after school availability to schedule when we reach out.
Please let us know if you have a preference for how you receive therapy services: Please note this is not a guarantee.

In PersonVirtualNo Preference
You MUST be in the state of Texas at the time you receive video services. Our clinicians are not licensed outside of Texas.
IMPORTANT INFORMATION ABOUT FAMILY THERAPY:
- Please provide your information in the client section. In the Issues/Concerns free response box please also add the other participants names, ages, and family relationship to you. If you are wanting individual sessions for yourself or your child, you will need to select individual therapy.
- At this time, family therapy is limited, with only virtual sessions available. Please note, family therapy may not be covered by insurance.
IMPORTANT INFORMATION ABOUT PSYCHOLOGICAL EVALUATION/TESTING:
- Estimated cost for testing is between $2,700-$3,500. Insurance benefits may vary.
- Our Psychologists are in-network with Aetna, BCBS, and Cigna. We do NOT accept Medicaid.
- At this time, our office is scheduling testing intakes for November 2023. Testing is estimated to be a 6 - 8 week process with multiple appointments in-person and virtually.
IMPORTANT INFORMATION ABOUT IQ/GIFTED TESTING:

These services are NOT covered by insurance. There will be a down payment required prior to the appointment. We offer these services to as young as 3 years old into adulthood.

Testing can range between $800 - $1,300 depending on what test you are needing completed.
IMPORTANT INFORMATION ABOUT OUR OTHER SERVICES:
- Our office DOES NOT provide medication or prescriptions. Please refer to your primary care physician or a psychiatrist for medication.
- Girl Group is not covered by insurance.
- If you are wanting to use insurance, please select Individual Therapy or Psychological Evaluation.

CLIENT INFORMATION - CONTINUED
Client's Name*

First NameLast Name
Client's DOB*

MonthDayYear
Date
Client's Primary Language*

EnglishSpanishOther
Unfortunately, we no longer have a Spanish Speaker for therapy. / Desafortunadamente, ya no tenemos un hispanohablante para terapia.
Is there any other language spoken in the home or that the client understands?*
This helps pair you with the most appropriate clinician
Client's Address

Street Address

Street Address Line 2

CityState

Zip Code
Client's Phone Number*
Client's Email Address*
example@example.com
* We require a copy of the client's state I.D. be uploaded to this form to process appointment requests.
Upload Copy of Client's State/Government Identification Card or Driver's License*

Cancelof

PARENT / LEGAL GUARDIAN'S CONTACT INFORMATION
Your Name*

First NameLast Name
Marital Status
Relationship To Client
Step-parents will NOT be able to schedule or sign consent forms for the minor unless you have proof of adoption. Please make sure to include biological parent's contact information as well as we will need to communicate through them first.
Your Primary Language

EnglishSpanishOther
Your Secondary Language
Is your address the same as the patient's address?

YesNo
Who does the child primarily live with?
Your Address

Street Address

Street Address Line 2

CityState

Zip Code
Your Phone Number*
Your Email Address*
example@example.com
* We require a copy of one the adult parent/guardian's state I.D. be uploaded to this form to process appointment requests.
Upload Copy of Your State/Government Identification Card or Driver's License*

Cancelof
Additional Parent/Guardian's Name

First NameLast Name
Relationship To Client
Step-parents will NOT be able to schedule or sign consent forms for the minor unless you have proof of adoption. Please make sure to include biological parent's contact information as well as we will need to communicate through them first.
Is Additional Parent's address the same as the minor patient's address?

YesNo
Additional Parent/Guardian's Address

Street Address

Street Address Line 2

CityState

Zip Code
Additional Parent's Phone Number
Additional Parent's Email Address
example@example.com

PAYER INFORMATION - SELF PAY OR INSURANCE PAYER
Do you have mental health insurance coverage?

Yes, I have mental health insurance coverageNo, I am a self pay client.
Please Note: Your Mental Health coverage may differ from your Medical coverage.

ADDITIONAL PATIENT INFORMATION
Due to the high demand of testing to be completed before the school year begins, psychological evaluations make take longer than the typical estimated time frame for completion. Please note: Testing sessions may be delayed up to a month or more following your intake appointment in order to serve as many members of our community as possible during this high demand period.
Please provide a brief description of the concerns/issues: *
Please Provide Reason for Testing:
Is this for an Application for a Program or School?
Is this for Gifted and Talented Identification?
If Applicable, please list any specific tests or types of testing required by the Program or School:
example: academic, emotional, learning, behavioral, cognitive testing
How did you hear about us?*

Google/Internet SearchFacebook/Social Media AdFamily/FriendPCP/PediatricianInsurance ProviderPsychiatrist/TherapistOther
If it was a Mental Health/Medical professional, please share who?

Next Steps and What to Expect
Next Steps for Scheduling*

Due to the HIGH VOLUME of request for services the estimated time frame for processing your request is 4 - 6 business days.Please look out for an email from GPS, PLLC or Simple Practice as that is the first line of communication our office will reach out through.
Insurance*

Insurance benefits are not checked until the intake has been scheduled. Mental Health coverage may differ from your Medical coverage. Please Note our office falls under a Specialist not PCP.Insurance Disclaimer: A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the primary policy holder/ subscriber's contract at time of service.
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New Client Request Form

You MUST be in the state of Texas at the time you receive video services. Our clinicians are not licensed outside of Texas.

CLIENT INFORMATION

Our office will require a copy of the legal guardianship, conservatorship, or power of attorney decree prior to scheduling an appointment.

A signed copy of the custody decree is required for minors in the case of divorce, guardianship appointed by the courts or adoption. If no custody decree is in place, we will need BOTH parent's contact information on file.

CLIENT INFORMATION - CONTINUED

Unfortunately, we no longer have a Spanish Speaker for therapy. / Desafortunadamente, ya no tenemos un hispanohablante para terapia.

* We require a copy of the client's state I.D. be uploaded to this form to process appointment requests.

PARENT / LEGAL GUARDIAN'S CONTACT INFORMATION

Step-parents will NOT be able to schedule or sign consent forms for the minor unless you have proof of adoption. Please make sure to include biological parent's contact information as well as we will need to communicate through them first.

* We require a copy of one the adult parent/guardian's state I.D. be uploaded to this form to process appointment requests.

Step-parents will NOT be able to schedule or sign consent forms for the minor unless you have proof of adoption. Please make sure to include biological parent's contact information as well as we will need to communicate through them first.

PAYER INFORMATION - SELF PAY OR INSURANCE PAYER

Please Note: Your Mental Health coverage may differ from your Medical coverage.

INSURANCE PAYER INFORMATION

Our office is considered in-network only if your mental health coverage is managed by Aetna, Blue Cross Blue Shield, or Cigna. If you have something outside of these 3, you will be considered Out of Network and responsible for the full price.

* If using insurance benefits, we require a copy of the FRONT and BACK of the insurance card to be uploaded to this form to process benefits and claims.

ADDITIONAL PATIENT INFORMATION

Next Steps and What to Expect