The Law Offices of Bonnie Z. Yates :: Intake Form

Note: Please provide ALL requested information. We cannot provide legal advice until you do so.

Child’s name: *
Child’s date of birth: *
Mother’s name: *
Father's Name:
Family’s home street address: *
Family’s city, state & zip: *
Home telephone number: *
Home fax number (if applicable):
Mother's cell phone: *
Mother's Email address: *
Name of Mother's employer: *
Employer Address: *
Mother's Job title: *
Mother's Work number: *
Mother's Work Fax (if applicable):
Father's cell phone number: *
Father's Email address: *
Father's Job Title: *
Father's Work number: *
Father's Fax Number (if applicable):
What is your child's eligibility or learning disability or diagnosis: *
Is your child eligible for Regional Center services? If so, which Regional Center? *
What services is your child currently receiving (ABA, LAS, OT, PT)? *
How many hours per week/month? *
How much out-of-pocket for each session of the above listed services? *
Who is your health insurance provider? *
Is your policy part of an employee benefit plan? If so, when is your open enrollment period? *
Is your policy an individual policy (separately purchased and not part of an employee benefit plan)? *
Are you a government employee? If so, who is your employer? *
Do you have an HMO or PPO? *
If you have an HMO, has your child’s primary care physician authorized/ recommended these services or referred you to someone who has?
Have you submitted claims for these services to your health insurance? If so, have any of these claims been denied? Please provide us with any documentation and correspondence you have related to these claims (claim forms, denial letters) *	Yes No
What remedy are you looking for in this case? *
How did you hear about us? If referred, who referred you? *

Intake Form - Insurance

Note: Please provide ALL requested information. We cannot provide legal advice until you do so.

If you do not hear back from us within three business days, please call us at (310) 204-6624.