New Client Information Form

Please correct the errors described below.

WELCOME! We are currently scheduling intake appointments via telehealth (video) due to the COVID19 pandemic. You will be asked in the form below if you would like to go ahead and schedule now, or prefer to be contacted when we return to the office. *We do not yet have a return date on the calendar and will continue doing intake appointments via telehealth through the summer.*

The information provided in this form will help us to determine whether we have a clinician who will be a good fit for your needs. Please be sure to answer every question. Our Client Care Coordinator will be in touch within 1-2 business days, unless you indicate you want to wait until we are scheduling in-office appointments.

This form is for use by potential clients/families only. If you are a third party who is interested in referring a client to us, please visit CampbellPsychPA.com/forms for a Referral Form. Thank you!

PLEASE NOTE: Our appointment hours are 8 AM - 5 PM, Mon-Thurs, and vary by therapist. Afterschool appointments are extremely limited - if you require appointments after 3 PM we may not be a good fit for your family. **Please note that completing this form does not guarantee an appointment.**

Contact Information

Information About Client

Please be sure to choose the correct year

Other Parent Information

If there is shared legal custody, we will need contact information for all individuals who share custody so that we can reach out to them to obtain consent. Visit http://campbellpsychpa.com/custody for more information.

Insurance / Payment

Insurance

We are in-network with several insurance plans. If your child is covered by more than one insurance policy, please provide information for EACH policy. If we are not in-network with your insurance, we are happy to provide services out-of-network. This means that you are responsible for paying our full fee at the time of service, and we will provide you with paperwork to submit to your insurance company for potential reimbursement. For more information about our rates and payment options, please visit http://campbellpsychpa.com/rates-insurance.

Insurance Policy #1 (Primary Insurance)

Insurance Policy #2 (Secondary Insurance)

Additional Insurance

Scheduling

Thank you! We will review the information provided and be in touch within 1-2 business days.

Your information will be encrypted.