ABA Intake Form Expand CHILD INTAKE FORM ABA Child Intake Form for Behavior Therapy/ABA Child's InformationChild's Name*Gender*MaleFemaleChild's Current Age*Date of Birth* Date Format: MM slash DD slash YYYY Name of SchoolGrade*No School YetPre-KKindergarten123456789101112Trade School/Post-SecondaryDo You Have a Primary Care Physician?*YesNoPrimary Care Physician's NamePrimary Care Physician's Phone NumberPrimary Care Physician's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your child currently being seen by a behavioral health technician?*YesNoDescribe your main concerns. Include when problems were first noticed, who noticed and where problems occur.*Why are you seeking services for your child?*Has your child’s physician noticed these concerns? If yes, what recommendations did he/she make?*How did you learn about us?*Are you currently utilizing any community resources (e.g. support groups, social groups, social services, school-based services or other social supports)?*List all other services your child has received, including counseling; psychiatry; physical, speech, occupational or ABA therapy, etc. If none, skip..Type of ServiceDates/AgesName of Provider To list multiple services/providers, click the plus tab on the right to create another row. Family InformationWith whom does your child live? (Check all that apply.)* Biological parent(s) Adoptive parent(s) Grandparent(s) Legal guardian(s) Sibling(s) Other List all family members who live with your child.*NameAgeRelation to the child To add additional family members, click the plus tab to the right.Please list family pets in the home. If none, skip.TypeName To add more than one pet, click the plus tab to the right. Parent InformationParent 1 Name* First Last Parent 1 GenderMaleFemaleParent 1 DOB* Date Format: MM slash DD slash YYYY Parent 1 Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 1 Phone No. 1*Parent 1 Phone No. 2Parent 1 Email Address* Enter Email Confirm Email Parent 1 Preferred Method of Contact*Phone No. 1Phone No. 2EmailParent 1 Employer*Parent 1 Job Title*Parent 2 Name First Last Parent 2 GenderMaleFemaleParent 2 DOB Date Format: MM slash DD slash YYYY Parent 2 Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 2 Email Enter Email Confirm Email Parent 2 Phone No. 1Parent 2 Phone No. 2Parent 2 Preferred Method of ContactPhone No. 1Phone No. 2EmailParent 2 Place of EmploymentParent 2 Job TitleAre there family circumstances that would be helpful to share with your child’s therapist such as medical issues or legal issues? (e.g., custody arrangements)*Are there any other languages spoken in the home? If yes, which language(s) and how often?*Do any other family members any diagnosis or known medical conditions/ disorders? (e.g., ADHD, autism)Relation to ChildRelated Condition/ Diagnosis? To add more than one, click plus tab to the right. Child's Health HistoryDescribe your pregnancy, including any complications.*Describe your labor/delivery, including any complications.*Type of birth (check all that apply):* Spontaneous (not induced) Induced Vaginal C-section Birth Place (hospital, etc.)*Birth Attendant Name (physician, midwife, etc.)Gestational Age (in weeks)*Birth Length*Birth Weight*NICU?*YesNoIf your child stayed in the NICU, for how long?Were there any complications after birth or during the first few weeks? (Check all that apply.)* Difficulty breathing Difficulty feeding Birth defect Jaundice Seizure Other None Has your child's hearing been tested?*YesNoIf your child's hearing has been tested, when and where?If your child's hearing has been tested, what was the determination?PassDid not passSeeking a follow-upDoes your child have an infectious or communicable disease?*YesNoUnsureIf your child does have an infectious or communicable disease, please describe.List any environmental or food allergies, please include adverse reactions to allergen.*List any routine medications your child is currently taking or has taken long term.MedicationDosesFrequencySide Effects To add more than one medication, click the plus tab to the right.Describe any other conditions or diagnoses identified by your child’s doctor or other professionals.Please list any spiritual or cultural variables that may impact treatment that we should be aware of.Click all that apply.* Breastfed Formula Fed Both If your child was breastfed, for how long? ( __ Months to __ Months.)If your child was formula fed, for how long? ( __ Months to __ Months.)At how many months-old did your child begin using a sippy cup? (If still not in use, skip.)At how many months-old did your child begin using an open cup? (If still not in use, skip.)At how many months-old did your child begin using a straw? (If still not in use, skip.)At how many months-old did your child begin using utensils? (If still not in use, skip.)Describe any difficulties with sucking, swallowing, chewing, eating different textures, etc.*FAVORITE FOODS*FOOD AVERSIONS*Child's Educational InformationName of SchoolClassroom TypeTeacher/GradeSchool Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Does your child have an IEP?*YesNoIf yes, please provide us with a copy of the most recent IEP and ETR. Child's Strengths and FavoritesDescribe your child’s strongest skills and personality traits. What makes your child unique?*FAVORITE ACTIVITIES / HOBBIES*FAVORITE TOYSFAVORITE MOVIESFAVORITE BOOKSParent Electronic Signature* First Middle Last Today's Date* Date Format: MM slash DD slash YYYY Child Emergency Contact Information Expand CHILD CARE EMERGENCY CONTACT INFORMATION Child's Name* First Last Child's Date of Birth* Date Format: MM slash DD slash YYYY Child's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Name* First Last Parent Home/Cell Phone Number*Parent Work Number*Parent Email Address* Enter Email Confirm Email Parent Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Place of Employment*Work TitleDepartmentWork Contact Person (who usually knows your whereabouts)Work Contact's Phone NumberParent/Guardian Name First Last Parent Home/Cell Phone Number*Parent Work NumberParent Email Address Enter Email Confirm Email Parent Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Place of EmploymentWork TitleDepartmentWork Contact Person (who usually knows your whereabouts)Work Contact's Phone NumberEmergency ContactsPerson to contact when attempts to reach parents are not successful and who may pick up the child. Emergency Contact No. 1* First Last Emergency Contact No. 1 Home/Cell Phone*Emergency Contact No. 1 Work PhoneEmergency Contact No. 2* First Last Emergency Contact No. 2 Home/Cell Phone* First Last Emergency Contact No. 2 Work PhonePersons Authorized to Pick Up the ChildWe must have written permission for anyone other than parent/ guardian to pick child up from the center. Name No. 1 First Last PhoneName No. 2 First Last PhoneName No. 3 First Last PhoneName No. 4 First Last PhoneChild's Medical Emergency ContactPhysician's Name* First Last Physician's Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Physician's Phone #*Dentist's Name (child's or parent's)* First Last Dentist's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dentist Phone Number*Child's Health InsuranceName of Insurance Plan*Certificate Number (or ID) #*Group #*Policy Holder’s Name First Last Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations*Parent/Legal Guardian Consent and Agreement for EmergenciesParent/Guardian No. 1 Consent Agreement* As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year. Parent Guardian No. 1 Electronic Signature* First Last Today's Date* Date Format: MM slash DD slash YYYY Parent/Guardian No. 2 Consent Agreement As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year. Parent Guardian No. 2 Electronic Signature* First Last Today's Date Date Format: MM slash DD slash YYYY Policies and Consent to Therapy Services Expand Therapy & Wellness Connection Policies & Consent to Therapy Services Therapy & Wellness Connection Policies* I have read and been given a copy of Therapy and Wellness Connection policies.Therapy & Wellness Connection Policies* The policies have been explained to me by a therapist at Therapy and Wellness Connection.Client Rights* Therapy and Wellness Connection has explained to me my rights as a client. I am aware that there is a copy in the office that I can see at any time or I may request my own copy.I consent for treatment in the following areas:* Speech therapy Occupational therapy ABA/Behavior therapy Physical therapy Intervention services Music therapy Tutor services Check all that apply.Parent/Guardian Electronic Signature* First Middle Last Today's Date* Date Format: MM slash DD slash YYYY Client CommunicationConsent* I give my consent for communication regarding client information, appointment times, or any necessary update via all electronic devices (cell phone, fax, email). All communication must be Monday through Friday between the hours of 8 a.m. to 5 p.m.Parent/Guardian Electronic Signature* First Middle Last Coordination of Care* I accept coordination of care. Photo Release Expand Photo Release for Social Media, Marketing & Media YES, I give consent to use photos of my child on ALL Social Media sites, marketing materials. I hereby grant to Therapy and Wellness Connection LLC, the right to interview, Photograph, and/or video record myself or my child and use the photo and/or other digital reproduction of me in any and all of its publications and in any and all other media social/media, whether now known or hereafter existing. I understand and agree that these materials will become the property of Therapy and Wellness Connection LLC and will not be returned. Additionally, I waive any right to any compensation arising or related to the use of the photograph.No, I do NOT give consent to use photos of my child on ANY Social Media sites or for marketing materials. I agree to the privacy policy.Child's Name* First Middle Last Parent's Name* First Middle Last Date* Date Format: MM slash DD slash YYYY Insurance Intake Form Expand Insurance Intake Form Client/Child's Name* First Middle Last Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance InformationAre you using insurance benefits to cover all or part of therapy services?*YesNoIf you are using insurance, indicate whether you are:Primary policyholderDependent relationship to primary policyholderInsurance Company Name*Insurance Company Street Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Insurance Company ID #Group #Policy Holder's Name First Last Policy Holder's Date of Birth Date Format: MM slash DD slash YYYY Policy Holder's EmployerCo-Pay AmountHave you reached your deductible?YesNoCo-InsuranceInsurance Information ReleaseConsent to Release Insurance Information By clicking this box, I hereby authorize Therapy and Wellness Connection to release to my insurance company, any information regarding this dx which is required to process my claims.Assignment of Insurance Benefits:Consent for assignment of insurance benefits. By clicking this box, I hereby assign my insurance benefits to Therapy and Wellness Connection.Today's Date* Date Format: MM slash DD slash YYYY Name of person filling out this form.* First Last Therapy & Wellness Connection Policies & Procedures Expand Therapy & Wellness Connection Policies