Schedule Appointment

Thank you for choosing All in 1 S.P.O.T. with TheraTalk. If you are interested in receiving services for your child or yourself, please fill out the following information. Please note that all information will be kept confidential. If you do not wish to submit your information online, you may also call us at 718-767-0071 or submit this information in-person at our office.

Section 1 - Patient Name *

First

Last

Patient Date of Birth *

Patient Gender *

Parent / Guardian Name *

First

Last

Relationship to Child *

Phone Number *

Address *

Email *

Primary Language Spoken *

Section 2 - Type of Service Requested (Check all that apply) *

If you selected "Other" above, please specify.

Section 3 - Insurance Company

(This field is not mandatory if you have received approval and are seeking services through the Board of Education. If so, please fill out all fields in Section 4)

Insurance Plan

Member's Name

Member ID #

Section 4 - Board of Education Information - CPSE

(This information is not mandatory if you wish to receive services through insurance. If so, please fill out all fields in Section 3)

CSE

Mandate

Administrator

Section 5 - I would like to pay privately

Yes
No (if no, all of section 3 or section 4 must be filled out)

Section 6 - Please list all days and times you/your child are available *

Section 7 - Please describes your concerns or any additional information you would like to provide below

Message

EVERYONE

deserves

A VOICE