New Patient Forms for Dr. Jennifer Gale

Assessment Services New Patient Forms for Dr. Jennifer Gale

Please return the first form: New Patient Intake Form and a copy of your child’s insurance Card to our office within five business days via email or fax (866-376-8067), as we verify patient benefits as a courtesy to you, and prefer ample time to contact your insurance to understand preauthorization procedures and to inform you of your co-pay responsibility for our service.

New Patient Intake Form

As soon as we receive the New Patient Intake Form we will verify your benefits, a process that can take up to 2 weeks. Once we have verified benefits we will call to review those with you and confirm the exact date of the evaluation. At that time we will schedule a 1 hour intake appointment, which is for parents/guardians to discuss concerns and outline expectations for the evaluation.

You should print and complete the following four forms on this page, and bring them 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.