Boston Neuropsychological Services, LLC

687 Highland Avenue, 2nd Floor Needham, MA 02494

Telephone: 781-559-8444
Fax: 781-559-8117

Date Completing Form

Are you or anyone in your immediate family a previous client of BNS?

Our current lead time is:

1-2 weeks for Intake Appointments, Evaluation approximately 1 month after Intake and Results typically 4 - 5 weeks after the Evaluation.

Your First Name

Your Last Name

Client First Name

Client Last Name

Client Date of Birth - Please make sure correct year chosen

Email address of contact

Phone number of contact

Your relationship to client if not the client:

Client's Home Address

City

State

ZIP Code

Has the Client had a Neuropsychological Evaluation completed within the last 12 months? If yes, please provide dates and providers in box below. We will need prior evaluations after Intake Appointment

If the client is a child, do they attend a charter school? If yes, please indicate the name of the school in the box below.

Description of Issues/Concerns Client is experiencing that results of a Neuropsychological Evaluation will be beneficial

We do NOT accept MassHealth or any of their products. This would be a Self-Pay. If your insurance is United Healthcare, please call them prior to submitting form to give their Behavioral Health Customer Service verbal permission to speak to Boston Neuropsychological Services regarding your benefits. Please get a name and reference number so we can use it when we call for benefits (Put in Box below)

United Healthcare Reference Name and Number

Please include all letters and numerals in Member ID ( Example: MTN960123456-02)

Health Insurance Name (ie: BCBS, HP, etc) Primary

Member ID # for Client - Primary

Health Insurance Name (ie: BCBS, HP, etc) Secondary

Member ID # for Client - Secondary

Insurance Provider Phone #

Name of Primary Subscriber

Date of Birth of Primary Subscriber

I am interested in

Neuropsychological Testing

Counseling

Forensic Consultation (Legal Case or Application for Services)

IEE - School Funded

Referred by Name and Contact Info

Name of your PCP or Pediatrician

Phone number

I have an Attorney

Name of Attorney with Contact Info (if applicable)

I have an Advocate

Name of Advocate with Contact info (if applicable)

By clicking submit, I give BNS permission to check my insurance benefits if applicable and to contact me with the the results.

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