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Are You or the Patient Under 18?*

Yes

No

Patient Full Name*

Date Of Birth*

Currently, no openings for Children Under 13

Name of Parent/Guardian*

Phone*

Email*

Patient/Client Home Address*

Preferred Language*

Other Language*

Preferred Days for Sessions*

Please select all that apply.

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays (Limited)

Saturdays (Limited)

Preferred Times for Sessions*

Please select all that apply.

Mornings

Afternoons

Evenings Only (Limited)

Health Information

Health Insurance*

Insurance Policy Number*

Is Medication Management needed?*

Reason(s) For Referral*

Please give us enough information to make a good match!

Specific Clinician Request

Enter the name of a preferred Revidas clinician (if any).

Doctor (PCP/Pediatrician) Name

Doctor (PCP/Pediatrician) Phone Number

Doctor (PCP/Pediatrician) Address

Street Address City State ZIP Code

How did you hear about us?

Referral Source (Google, Social Media, Other) or Name of Person Who Referred You*

Referral Phone Number (if applicable)

Referral Email (if applicable)

Is DCF Involved?*

Yes

No

Please list DCF Social Worker & Phone Number

Monday	09:00 am – 05:00 pm
Tuesday	09:00 am – 07:00 pm
Wednesday	09:00 am – 07:00 pm
Thursday	09:00 am – 07:00 pm
Friday	09:00 am – 05:00 pm
Saturday	By Appointment
Sunday	Closed

Location

Hours

Contact us to schedule a therapy session today.

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Health Information

How did you hear about us?

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