Follow the steps to complete the intake form successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor. This will allow you to begin entering the required information.
2. Start by entering the child's name as listed on their insurance card. Follow this with the name your child is commonly called. Fill in their date of birth and social security number.
3. Indicate the child's gender by selecting either 'Male' or 'Female'. Complete the child's address, including street, city, state, and zip code.
4. Provide two phone numbers for appointment reminders. For each number, specify the name listed under that phone.
5. Identify the responsible party for the billing account. This can be the parent or guardian bringing the child in for treatment.
6. Enter the responsible party’s address, phone numbers, and social security number, along with the employer's name.
7. Fill in both primary and secondary insurance information, including subscriber names, dates of birth, and relation to the patient.
8. If applicable, indicate whether you are using your Employee Assistance Program (EAP) for initial visits and provide relevant insurance name and authorization number if so.
9. Complete information regarding who the child lives with and their relationship to the child, as well as details about legal custody, if applicable.
10. Review and sign the financial policy and consent sections, ensuring you understand and agree to the terms laid out. Include the date of signature.
11. Finally, check all fields for accuracy. Save the completed form, and then download or print it for your records. You may also share it as required.

Complete the Pitts & Associates Child Intake Form online today for a smooth start to your child's treatment process.