Forms

Clients, Parents/Guardians. 

To start services Complete this Quick 5 minute Intake form to be scheduled for your first Appointment.

Fill out one form for each person who would like to start services (example: multiple siblings). We will call you within 3 business days to schedule your appointment.

Client Intake/ Consent Form

If you need to Verify Insurance or Refer Someone

Accepting the following Insurance Carriers: Superior HealthPlan, Wellpoint/Carelon, Texas Children’s Health Plan, Molina Health, Ambetter by Superior Health.

Fill out one form for each person who would like to start services (example: multiple siblings)

Referral and Verification of Benefits
Use the links below if you need to release information or medical records to a person, doctor, clinic, or organization.
General Release of Information

Limited Release of Information for School, Teachers, or School Visits.

Release of Information for School

Please Fax Any Records Related To Referrals To: 281-503-7605 Or Secure Email: aburns@alpharecoverytexas.com