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Square One
Specialists in Child and Adolescent Development
About Us
About Square One
Staff
Judith Axelrod, MD
David Causey, PH.D.
Ann Ronald, M.ED., PH.D.
Todd Johnson, M.Ed.
Amy Usher, Ph.D.
Kelly Slaughter, PhD
Elizabeth Cook, APRN
Christina King, MAT
Genevieve Mulkins, APRN, PMHNP-BC, FNP-BC, DNP
Sarah Aroh, APRN, PMHNP-BC, FNP-C
Frequently Asked Questions
Forms
New Patient Form
Square One Forms
Prescription Request Form
Contact Us
Evaluation
Our Comprehensive Team
Neurodevelopmental
Psychological/Educational
Neuropsychological
Treatment
Psychotherapy
Medication Management
Telehealth
Insurance
Insurance Coverage
Filing Claims
CMS 1500 Insurance Claim Form
Parents
Make a Payment
Refill Requests
Helpful Resources
New Patient Form
About Us
About Square One
Staff
Judith Axelrod, MD
David Causey, PH.D.
Ann Ronald, M.ED., PH.D.
Todd Johnson, M.Ed.
Amy Usher, Ph.D.
Kelly Slaughter, PhD
Elizabeth Cook, APRN
Christina King, MAT
Genevieve Mulkins, APRN, PMHNP-BC, FNP-BC, DNP
Sarah Aroh, APRN, PMHNP-BC, FNP-C
Frequently Asked Questions
Forms
New Patient Form
Square One Forms
Prescription Request Form
Contact Us
Evaluation
Our Comprehensive Team
Neurodevelopmental
Psychological/Educational
Neuropsychological
Treatment
Psychotherapy
Medication Management
Telehealth
Insurance
Insurance Coverage
Filing Claims
CMS 1500 Insurance Claim Form
Parents
Make a Payment
Refill Requests
Helpful Resources
New Patient Form
You are here:
Home
New Patient Form
New Patient Form
To begin the process of allowing us the opportunity to support you and your child or adolescent,
please fill out the information below to let us know more about your concerns. We will review this information and communicate back to you with any additional questions we have that will help us to guide you with service recommendations.
PATIENT’S NAME and PERSONAL INFORMATION:
Name
(Required)
First
Middle
Last
Name Patient Likes to Go By:
Birthdate
(Required)
MM slash DD slash YYYY
Gender
(Required)
Patient’s Primary Residence
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Patient’s Second Residence If Applicable
Street Address
City
State / Province / Region
ZIP / Postal Code
(1) PARENT NAME and PERSONAL INFORMATION:
Name
(Required)
First
Middle
Last
Occupation
(Required)
Birthdate
(Required)
MM slash DD slash YYYY
Email
(Required)
Phone
(Required)
Relationship to the Patient:
(Required)
Biological Parent
Step Parent
Foster Parent
Parent (child was adopted)
Other
HIPAA CONSENT TO LEAVE A MESSAGE - Email communications are password secure but not encrypted and may be subject to unauthorized redisclosure or hacking: I do give permission to leave relevant healthcare information on my cell phone/email:
(Required)
Yes
No
(2) PARENT NAME and PERSONAL INFORMATION:
If you are the only parent, check the box below.
I am the only parent.
Name
(Required)
First
Middle
Last
Occupation
(Required)
Birthdate
(Required)
MM slash DD slash YYYY
Email
(Required)
Phone
(Required)
Relationship to the Patient:
(Required)
Biological Parent
Step Parent
Foster Parent
Parent (child was adopted)
Other
HIPAA CONSENT TO LEAVE A MESSAGE - Email communications are password secure but not encrypted and may be subject to unauthorized redisclosure or hacking: I do give permission to leave relevant healthcare information on my cell phone/email:
(Required)
Yes
No
Parents / Guardians are:
(Required)
Married
Unmarried
Single
Domestic Partnership
Seperated
Divorced
Widowed
Other
Explain
Legal Custody Arrangement (if relevant):
Joint Legal Custody
Joint Physical Custody
Sole Legal Custody
Sole Physical Custody
Who Lives in the Home with Your Child/Teenager?
(Required)
Please Let Us Know Below the Reasons and Concerns for Seeking Our Services:
(Required)
Feel Free to Tell Us Any Positives about Your Child/Teen or Anything Else You'd Like Us to Know:
What Services Are You Seeking from Square One at This Time?
(Required)
Comprehensive Evaluation / Diagnostic Assessment
Educational / Cognitive Evaluation
Counseling/Therapy
Medication Evaluation / Consultation Only
Not Sure (Don’t Worry – Our Job Is To Guide Families With This Question)
Please List If There Is a Specific Square One Clinician(s) You Are Requesting to See:
How Did You Learn about Square One?
Pediatrician
School
Another Square One Family
Your Own Previous Experience With Square One
Internet
Other
Explain
PATIENT'S SCHOOLING INFORMATION:
Current School
(Required)
Grade
(Required)
If your child/teen currently receives educational services / accommodations, please describe:
Has your child had education/psychological testing with a School Psychologist or Clinical Psychologist?
(Required)
Yes
No
With Whom
Date(s)
If possible, please provide approximate age/grade of the testing and other relevant information you might like to share (e.g., reasons for the testing, conclusions / diagnoses, etc.)
DEVELOPMENTAL HISTORY
Has your child received any of the services listed below? If so, please list the service provider (if possible) and provide the approximate ages (or dates if preferred) for these services:
First Steps Intervention
(Required)
Yes
No
Provider:
Age(s)
Reason(s)
Speech Language Therapy
(Required)
Yes
No
Provider:
Age(s)
Reason(s)
Occupational Therapy
(Required)
Yes
No
Provider:
Age(s)
Reason(s)
Physical Therapy
(Required)
Yes
No
Provider:
Age(s)
Reason(s)
Counseling/Psychotherapy
(Required)
Yes
No
Provider:
Age(s)
Reason(s)
Hearing/Auditory Processing
(Required)
Yes
No
Provider:
Age(s)
Reason(s)
Psychiatrist/Psychiatric Nurse Practitioner
(Required)
Yes
No
Provider:
Age(s)
Reason(s)
MEDICAL INFORMATION & HISTORY
Please put N/A in the sections that don't apply.
Hospitalizations:
(Required)
Surgeries:
(Required)
Medical Tests:
(Required)
History of Ear Infections/Ear Tubes:
(Required)
Past/Present Medical Diagnoses:
(Required)
Current Medications:
(Required)
Child's/Teen's Primary Care Physician/Pediatric Practice:
(Required)
Primary Care Contact Information:
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