Power of Play | SimplePractice

Reason for care

Why you are seeking therapy for your child

Provide as much detail as you are comfortable sharing (e.g., My child is 9 years old and is struggling with behaviors at school, conflict with their siblings, and a recent move to a new city)

Limited to 600 characters

Administrative

Referral source

Enter how you were referred to our services

If you are divorced/separated or in the process of divorce/separation, do you share legal custody of your child?

N/A Yes (I share legal custody of my child with someone else) No (I retain sole legal custody of my child)

Are you seeking therapy for your child in response to a court order?

Yes No

Billing & Payment

I do not bill insurance directly, please indicate below that you understand that payment for sessions would be required at the time of service for your child.

Yes, I understand

I am interested in receiving a SuperBill for my child's services, which I can submit to my insurance for potential reimbursement (payment is still due at the time services are rendered for your child)..

Yes, I am interested in receiving a SuperBill No, I am not interested in receiving a SuperBill

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.

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