New Patient Forms for Dr. Jennifer Gale

Please return the following items within five business days via email or fax (866-376-8067):

As soon as we receive the New Patient Intake Form we will verify your benefits, a process that can take up to 2 weeks. We verify patient benefits as a courtesy to you to understand preauthorization procedures and to inform you of your co-pay responsibility for our service.

Once we have verified benefits, we will call to review them with you and to confirm the exact date of the evaluation. (Therefore, please send in the New Patient Intake Form and insurance card within in the five business days in order to maintain current evaluation date.) During this call, we will schedule a 1-hour intake appointment, which is for parents/guardians to discuss concerns and outline expectations for the evaluation.

Please print and complete the following forms on this page to bring with you to the parent/guardian intake:

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The following form should only be completed by a custodial parent seeking evaluation services without the dual consent of the non-custodial parent.