Let's Get Started - Kidstuff Counseling

Full Name of New Client Needing Appointment

Full Name of Parent or Legal Guardian

Address

City/Zip

Date of Birth

Phone

How did you hear about us?

What Are Your Preferred Times and Dates to Schedule an Appointment?

What Are Your Main Questions or Concerns?

Telehealth Sessions Okay?

No Yes

Does the Client Have Medicaid?

No Yes

What Is the Medicaid ID Number? (if no Medicaid, type in None)

Does the Client Have Private Health Insurance?

No Yes

Name of the Private Health Insurance

Member ID#

Group ID#

For insurance clients only: are you interested in learning more about the KidStuff CARE Discount Program?

No Yes

Let’s Get Started