Jeri Penkava | New Patient Request
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New Patient Request


    Please fill out the following contact form with patient information, main concerns, and the type of appointment you need (evaluation for a new diagnosis, follow-up care, integrative treatment, or neurofeedback therapy).
    You may also send a copy of your insurance card and photo ID to adhdplus.records@att.net or fax to 210-403-2350.

    By submitting this form and checking the SMS consent box, you agree to receive SMS messages from Holistic Developmental Peds & Integrative Med PLLC regarding appointment reminders, service updates, and responses to your inquiries. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out at any time. Reply HELP for assistance.

    Patient Name*:

    Birth Month:

    Birth Day:

    Birth Year:

    Parent or Guardian:

    Phone*:

    Email*:

    Type of appointment requested:

    Current Insurance:

    Brief description of the medical, academic or behavior problem:


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    Privacy Policy
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    Terms & Conditions.

    We will contact you to advise on how to proceed for the full evaluation of you or your child. Thank you for your confidence in our office!