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Help starts here

This 5-minute form helps us get to know you

01

Tell us about yourself

Basic information about your child and family helps us customize our services to your needs

02

Insurance Details

Provide your insurance details if you will be using to pay for treatment

03

Help us understand your needs

Share what brings you here so we can align our services with your goals

04

Finish up and get started

Review your details and submit the form so we can get started on your personalized journey

Get Started

Step 1

Tell us about yourself

Are you a parent or referring on behalf of a parent/family?

I am a parent requesting help

Submitting a referral on behalf of a parent

Name of Person Submitting Referral

Agency Submitting Referral (if applicable)

Phone Number

Email

Tell us about yourself

Your name

Relationship to the child

Your family’s location

Your Email ID

Your phone number

Preferred communication method

By checking this box, you agree to receive text messages from Pariva Health related to program information and enrollment. Standard message and data rates may apply. Reply STOP to cancel and HELP for help.

Tell us about the parent

Parent name

Relationship

Family’s location

Parent Email ID

Parent phone number

Preferred communication method

Tell us about the child

Child Name

Gender of the child

Child date of birth

Step 2

Insurance Details

Provide insurance details you will be using for the treatment (if applicable)

Do you have insurance?

No

Yes

Name of Insurance Plan

Policy Number

Group ID (Optional)

Primary Card Holder Name

Primary Policy Holder Date of Birth

Insurance Company Phone Number (located on back of card)

Primary Card Holder's Address

Do you have Secondary Insurance ?

Name of Secondary Insurance Plan

Policy Number

Primary Card Holder Name

Primary Policy Holder Date of Birth

Primary Card Holder's Address

Step 3

Understanding your needs

Choose one or more of the following

Select from our existing services, specify a particular area of need, or opt to discuss your questions or concerns with us directly.

Family Support Program

If you have a child who is neurodivergent or who faces particular challenges in behavior or development, our multidisciplinary experts work with you and your child to help the entire family thrive.

Virtual Diagnostics

Get an expert opinion about your child’s behavior and development, and whether your child has a clinical diagnosis.

Other

Have something specific in mind? Tell us more. One of our experts will reach out to you with information or recommendations.

Family Support Program

Please briefly describe your primary concerns and areas of need for your child/family:

Virtual Diagnostic Services

Has your child previously been evaluated by a Psychologist/Psychiatrist?

Yes

No

Date

Does your child have a mental health diagnosis?

Yes

No

Please briefly describe your primary concerns and why you are seeking an evaluation for your child at this time

Other Needs

Please briefly describe your primary concerns and areas of need for your child/family:

Step 4

Finish up and get started

Take a moment to review your information, then let's begin your customized experience

Review your details

Feel free to revise any of your answers, then submit the form. One of our team members will reach out soon.

Referral’s details

Name of Person Submitting Referral

John Mathew

Agency Submitting Referral

Child Care

Phone Number

+1 987 658 6584

Email

[email protected]

Your details

Your name

Jack Reacher

Relationship to the child

Father

Your family’s location

New York

Your Email ID

[email protected]

Your phone number*

+1 896 784 5268

Preferred communication method

Phone

Parent details

Parent name

Jack Reacher

Relationship

Father

Family’s location

New York

Parent Email ID

[email protected]

Parent phone number

+1 896 784 5268

Preferred communication method

Phone

Child details

Child Name

Alex costa

Gender of the child

Male

Child date of birth

23rd Mar, 2010

Insurance details

Name of Insurance Plan

Healthcare Insurance

Policy Number

PC547867H475

Group ID

5478

Primary Card Holder Name

Jack Costa

Primary Policy Holder Date of Birth

16th Feb, 1988

Insurance Company Phone Number

+1 896 875 9854

Primary Card Holder's Address

Secondary Insurance Details

Name of Secondary Insurance Plan

Healthcare Insurance

Policy Number

PC547867H475

Primary Card Holder Name

Jack Costa

Primary Policy Holder Date of Birth

16th Feb, 1988

Primary Card Holder's Address

+1 896 875

Family Support Program

My primary concerns and areas of need for your child/family:

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Virtual Diagnostic

Has your child previously been evaluated by a Psychologist/Psychiatrist? : Yes/No
Date: 16th Feb, 2022
Does your child have a mental health diagnosis? : Yes/No

Please briefly describe your primary concerns and why you are seeking an evaluation for your child at this time:

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Other Needs

My primary concerns and areas of need for your child/family:

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Pariva Health Team

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Phone number: +1 857-557-6146

Email Address: contact@parivahealth.com

Our Address: 500 Grossman Drive, #1120, Braintree, MA, 02184

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