New client registration

Welcome!

We are so excited that you have chosen to get this process started. I hope you find this intake protocol to be an efficient and positive experience.

To begin, please complete this intake form and we will contact you within 24-48 hours to schedule your first appointment. If you have any questions or concerns, please contact us at jgallant@flcbh.com or 561.880.4225.

** It has come to our attention that this form is not working for some individuals. If you hit submit and get an error, please contact Dr. Gallant at jgallant@FLCBH.com. We apologize for this inconvenience.

Name of Client *

Date of Birth *

Are you filling this form out on behalf of yourself or someone else? *

This form must be completed by a legal guardian for all prospective clients under the age of 18. Consent from a legal guardian will need to be obtained prior to our scheduling if filled out by a non-legal guardian.

Name of person filling out the form (if different from client)

Relationship to client

Reason for referral? *

Primary Address *

City *

State *

Zip Code *

Email *

Phone Number *

Preferred contact method to schedule an appointment

Phone call
Email
Text

How did you find out about us?

If you were referred by a doctor or pediatrician, please provide their name

Preferred Payment Option

Select Insurance provider

Dr. Gallant only accepts United Healthcare, Cigna, and UMR insurances.

Insurance Policy Holder Name

Policy Holider Date of Birth

Insurance Holder Member ID

Insurance Group Number

What is the 1-800 provider number on the back of the card?

New client registration

Welcome!

We are so excited that you have chosen to get this process started. I hope you find this intake protocol to be an efficient and positive experience.

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About Us

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