At the James L. Dennis Developmental Center, our Intake Process consists of two parts: “Part 1: Physician” form (2 pages, completed by the PCP’s office) and “Part 2: Parent/Guardian” form (2 pages, completed by the patient’s parent/guardian). These important intake forms assist our clinic in appropriately scheduling services to address clinical concerns and focus on the family’s goals for their child.
Once Intake Request form Part 1 and the insurance referral form are received, we will send Intake Request form Part 2 to the patient’s parent(s)/guardians. Alternatively, the Intake Request Form Part 2 can be faxed along with Part 1. Once the Intake documents are received, our triage team can review the request and assign an appointment. Our scheduling staff will notify the PCP and the parents of the appointment date and time.
Briefly, the Intake Request process and the associated timelines are as follows:
- When Intake Request – Part 1: Physician form is faxed to our Center, the PCP’s office will receive a return fax within 24 hours (or next business day), acknowledging that we have received the form. If you do not receive this faxed response, please call 501-364-5402.
- The Intake Request – Part 2: Parent form will be mailed (if not already faxed from the PCP’s office) upon receipt of the Intake Request – Part 1.
- Parents will have 14 days to return the Intake Request – Part 2: Parent form.
- To complete a patient intake file for appropriate appointment(s) scheduling, all 3 components must be received: Intake Request – Part 1: Physician form, Insurance/Medicaid Referral, and Intake Request – Part 2: Parent form.
- 14 days after your initial faxed intake, if we have not received all three Intake components, the intake file will be closed. We will contact the PCP’s office via fax to inform the PCP of the action taken.
Intake Request-Part 1: Physician [PDF]
Intake Request- Part 2: Parent/ Guardian [PDF]
Requesting an Evaluation from the School (61.85 kB) [PDF]