Holistic Child and Family Practice, PLLC

Reason for care

What would you like our help with?

Limited to 600 characters

Administrative

How did you hear about us?

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

Insurance card upload

Upload a photo of your insurance card

What gender is registered with your insurance?

If you plan on using insurance, we need to know what gender is registered with them. If you have questions, please reach out to your insurance company.

If you are not the main policy holder for your insurance, please include the legal name and date of birth of the policy holder:

If you are using insurance, we ask that you also upload your driver's license. Please mark below once you have (if applicable):

I have uploaded my driver's license I am not using insurance

Client Preferences

What are your preferred appointment times?

After school only Would prefer after school, but can make any time work No preference

What is your preferred modality for care?

Are you open to seeing an intern?

Note: interns currently have the most availability, especially for after school slots

Yes! No, I need an associate/to use my insurance I need more information before I can say

Is there anything else that you would like us to know?

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.

Who would be receiving care?

Your info