New Client Inquiry

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New Client Inquiry

We will use this information to confirm your insurance coverage if any

Name of New Client *

Date of Birth *

YYYY

Phone number *

Email *

Collateral contact

If you are helping on the behalf of someone else. Please leave information about your name, contact info and your relationship to the client.

Payment *

Currently we are in network with the following insurances. If we do not take your insurance you will need to pay out of pocket and submit a claim to your insurance

Medicare

Contra Costa Health Plan

Out of Network (Private Pay)

Primary Insurance Member ID

Secondary Insurance

Secondary Insurance Member ID

I have a referral

Yes

Clear selection

Referring provider

I am would like to hear about

Assessment wait time is about 3-4 months from the initial referral.

We are full of therapy clients and have a waitlist. We are hoping to hire more therapists soon. Any new therapy referrals will be placed on a waitlist.

Therapy

Assessment

Other:

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Are you able/interested in meeting via telehealth? *

Intakes for assessment are via telehealth or phone. Psychotherapy we can meet in person or via telehealth. Please let us know if you have any concerns or preferences.

What brings you to NSNP?

Alzheimer’s disease

ADHD

Autism

Bariatric Surgery

Brain Injury (TBI)

Dementia

Executive Function

Gender Affirming Evaluations

Memory

Multiple Sclerosis

Parkinson’s Disease

Post Concussion Syndrome

Specific Learning Disorders

Stroke

Trauma

Other:

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