REFER A PATIENT

Please fill out the intake form below and submit the available supporting documentation.

DOWNLOADABLE INTAKE FORM

Client Intake Form

Referring Physician Information

Physician's Name

Practice Name

Phone Number

Fax Number

Client's Information

First Name

Last Name

Date of Birth

Age

Social Security Number

Recipient Number

Diagnosis

Parent/Guardian Contact Information

First Name

Last Name

Relationship

Phone

Home Address

Insurance Information

Primary Insurance

Policy Holder

Supporting Documentation Checklist

Please checkmark the documents submitted below.

Letter of Necessity

Diagnosis Assessment/Neurological Assessment

Individualized Educational Plan (I.E.P) / Early Steps Evaluation

Physician Assessment with behavioral intervention prescription code and diagnosis

Letter of Necessity

Diagnosis/Neurological Assessment

Individualized Educational Plan...

Physician Assessment...

Date

Initials

I declare that the information I've provided is accurate and complete.

Thank you for thinking of us for your patient's behavioral needs.

One of our team members will be in contact with the client's guardian to arrange a consultation.

REFER A PATIENT

Client Intake Form

Referring Physician Information

Client's Information

Parent/Guardian Contact Information

Insurance Information

Supporting Documentation Checklist

RESOURCES

POLICIES

CONTACT US

SHOP POLICIES

ABOUT US

PRIVACY POLICY

TERMS OF SERVICE

CAREERS

CONSULTATION REQUEST

CONTACT INFORMATION

1490 S Military Trail, Suite 7,
West Palm Beach, FL 33415

info@coralbehavioral.com

(561) 323-2552

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