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2211 Norfolk Street
Suite 460
Houston, TX 77098

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Tel: 713-523-0058
Fax: 713-523-1165

info@adhdtx.com

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Clinic for Adult Attention Problems, P.A.

Delivering State of the Art Assessment and Treatment
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Make an Appointment
For an Evaluation or For Behavioral Therapy

Note: All information received from this site is held in a secure server and kept confidential. Only authorized personnel will view this information.

 
General Information
Patient Name
Parent/Guardian Name (if applicable)
Home Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email Address
Date of Birth
SSN
Age
Marital Status
Married Single Divorced
Sex
Male Female
Employer
Occupation
Insurance Information
Self Pay
Yes No
Insurance
Yes No
If using insurance, please fill out the information below:
Insurance Company
Policy Number
Group Number
Phone Number
(For Mental or Behavioral Health Benefits/Eligibility)
Primary Card Holder's Name
(Insured--if different from above)
Social Security Number of Card Holder
(Insured--if different from above)
Member ID# of Card Holder
(If different from SSN#)
DOB of Card Holder:
(Insured--if different from above)
Student Information (if applicable)
Elementary
Middle School
High School
University
 
Classification
Freshman
Sophomore
Junior
Senior
Name of School
Referral Information
How were you referred to us?
Include a brief description of your problem and why you are seeking an assessment.
Saturday Appointment Agreement
I, knowing that my account information is private, hereby agree to provide the Clinic for Adult Attention Problems, P.A., with my credit/debit card information if my initial appointment occurs on a Saturday.
I hereby decline to provide the Clinic for Adult Attention Problems, P.A., with my credit/debit card information and acknowledge that my initial appointment cannot occur on a Saturday without a method of payment on file.

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