Referral Form

For Patients & Providers. Please note, that we do not see children under the age of 9 years old in MA and under the age of 6 years old in California

Will this appointment be for you or are you making a referral for someone else?

Myself

Minor

I am making a referral for someone

Referring Practice Name *

Referring Medical Provider Name *

Referring Provider Email *

Referral Source Phone Number

Preferred Method of contact *

Fax

Phone

Text

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Address (Street, City, Zip) *

What is the patient's medicaid or member ID number? *

If using self pay, please list "Self Pay"

Patient Gender *

Male

Female

Non-Binary

Pronouns *

He/Him

She/Her

They/Them

If you share custody, does the other parent know that you are pursuing testing for the child at the current time? Will they also want to be at the intake appointment or schedule a separate intake appt to go over their concerns? Please provide contact info of other parent if applicable

Parent or Guardian if applicable

Primary Contact First and Last Name (if other than patient) *

Primary Contact Cell Phone *

Primary Contact Email *

Preferred Method of Contact: *By selecting your preferred method of contact, you authorize us to communicate with you about testing and future appointments through this method. Message and data rates may apply. I can opt out at any time by emailing [email protected] or calling 800-593-2560

Phone

Text Message

Voicemail

To improve the quality of our testing: we like to send your therapist our online therapist input form to be able to provide any valuable input they may have on your work together. Once received, this information is integrated into your report. If you have a therapist you have worked with in the past or are working with now whom you think would be helpful- please provide their email address or other contact info below. By providing this info below and signing, you are authorizing us to contact this outside party, acknowledging that you have engaged us for your neuropsychological testing, and ask for their input.

Signature to approve the above *

Clear

Please upload any relevant files to our HIPAA compliant server (prior testing, payment info, relevant records, etc.)

Please upload a copy of the front of the insurance card(s) you would like to use for your services Please make sure the image is not blurry.

Please upload a copy the back of the insurance card(s) you would like to use for your services.

Primary Subscriber DOB (if not the patient)

Primary Subscriber (if not the patient)

Primary Subscriber's Home Address

If you would like our office to share the results of you or your child's testing with anyone after testing is complete, please provide their contact info (website, email, phone, or fax) and role (teacher, therapist, counselor, pastor, doctor). By providing this info below and your signature, this will act as a release of information, granting us the ability to automatically share the results of testing after testing is complete. You can opt out at anytime by emailing [email protected]

Signature to approve above *

Clear