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Contact & birth details

Address *

City *

Zip Code *

Date of Birth *

A bit more about you

This helps us match you with the right clinician and is kept confidential.

Gender *
—Please choose an option—MaleFemaleOther

Race *
—Please choose an option—WhiteBlack / African AmericanAmerican Indian / Alaska NativeAsianNative Hawaiian and Other Pacific Islander

Ethnicity *
—Please choose an option—Hispanic OriginNot of Hispanic Origin

Marital Status *
—Please choose an option—Single (Never Married)MarriedDivorcedWidowedDomestic Partnership

Parent / Guardian (if applicable)

Insurance & care team

Insurance Name * (Write Self Pay / Sliding Scale if applicable)

Insurance Member ID * (Write Self Pay / Sliding Scale if applicable)

Primary Care Physician * (Write N/A if applicable)

Psychiatrist * (Write N/A if applicable)

Appointment preferences

Requested Service Modality (optional)
—Please choose an option—At our CenterAt HomeAt SchoolVia Telehealth

BAS Office Location Preference *
—Please choose an option—Doral: 1414 NW 107TH AVE, SUITE 109, 33172Sunset: 9415 Sunset Drive, SUITE 123, 33173

Preferred Language *
—Please choose an option—EnglishSpanishBilingual

Service Requested / Description (optional)

Referral & school info

Only fill this in if it applies to you.

Referred by (optional)

Referral Phone Number (optional)

Referral Email (optional)

School Name * (Write N/A if applicable)

School Grade (optional)
—Please choose an option—Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade

Emergency contact

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

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