For Patients

The following forms are important and will help us establish a clear and effective relationship. To print the forms will require Adobe Acrobat Reader. If you do not have this program on your computer, you can download it for free by clicking here.

PLEASE COMPLETE BEFORE YOUR FIRST APPOINTMENT:

Office Policies and Procedures This form explains my office policies, includes a description of my services, and contains important information about your confidentiality. If you have questions after reading this form, please bring them up when we meet.

Notice of Privacy Practices I am required by law to provide you with a copy of the HIPAA Notice of Privacy Practices. This notice is meant to help you understand your rights and protections related to the use and disclosure of your protected health care information. Please keep the Notice for your records and sign the Privacy Notice signature page.

Biographical Information Prior to our first session, please complete the Biographical Questionnaire. This form provides important details about yourself and your background. The information you provide helps me understand who you and your concerns.

Authorization to Disclose Protected Health Information Complete and sign this form only if there are other individuals with whom you want me to communicate regarding your evaluation. This form gives your permission for me to discuss your evaluation with other parties (for example, your primary care physician or other care providers).

Consent for Neuropsychological Services This form explains the neuropsychological and psycho-educational evaluation process, and includes a description of the comprehensive evaluation. It also contains important information about your confidentiality.

Informed Consent for Tele-NP This Informed Consent for Tele-NP (Tele-neuropsychology) contains important information about conducting neuropsychological interviews, testing, and feedback sessions using the phone or the Internet.

Informed Consent for In-Person Services During COVID-19 This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis.

Payment for Services

Click “Pay Now” below and you’ll be taken to PayPal’s secure site to complete the payment. Fill in the amount you wish to pay on that form, under “Item Price”.

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