Online Intake Form

Please select the best option below to help guide you through the Intake Form

Are you coming to therapy because of a Worker's Comp claim?  Why choose this?
Are you coming to therapy because of an Auto or School insurance claim?  Why choose this?
This is not a Worker's Comp, Auto or School claim.

 

Is the Patient under the age of 18 or not the primary insurance holder?

Yes, the Patient is either under the age of 18 and/or not the primary insurance holder
No, the Patient is over 18 years of age and the primary insurance holder

 

Does the primary insurance holder have secondary insurance?

Yes, the primary insurance holder has secondary insurance that needs to be entered
No, the primary insurance holder does not have secondary insurance