New Client Intake Questionnaire

Office Locations

Westchester, NY, and Northampton, MA

(413) 270-2003

Client Information

First name

Last name

Primary phone number

Race and Ethnicity

Birth Sex and Gender Identity

Email address

Date of birth

Street Address

City, State, and Zip Code

BCBS Insurance Information

If you are a BCBS member, please enter your membership ID (otherwise leave this field blank):

If the patient is not the primary insurance subscriber, please list the primary insurance subscriber's name and date of birth (otherwise leave this field blank):

Referral and Brief History

Primary care provider

What is your doctor's name?

Referring provider (if not primary care provider)

Who referred you for a neuropsychological evaluation?

Please list any mental health conditions that you have been treated for.

Please list the medications you are taking and for what conditions.

Reason for referral and any other information:

How can this evaluation be most helpful to you?

Thank you for completing this form. If Dr. Brummett has an opening, he will reach out to you for scheduling. If you do not hear back from him, you will automatically be added to his waitlist. Thank you!

Name of person completing this form

After completing the form, click the SUBMIT QUESTIONNAIRE button below.

Your information will be encrypted.

Bradley Brummett, PhD, ABN

Board Certified in Clinical Neuropsychology, he/him

Bradley Brummett, PhD, ABN, is a clinical neuropsychologist with 20+ years of experience. His areas of expertise include autism spectrum disorders, traumatic brain injury, dementias (e.g., Alzheimer's disease), ADD/ADHD, multiple sclerosis, Lyme disease, cerebrovascular accident/stroke, and cognitive changes associated with psychiatric conditions. Dr. Brummett conducts evaluations for individuals age 17 and older.

Phone: (413) 270-2003, Fax: (413) 585-9902
www.ncsnoho.com
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New Client Intake Questionnaire

Office Locations

Client Information

BCBS Insurance Information

Referral and Brief History

***After completing the form, click the SUBMIT QUESTIONNAIRE button below.***

Office Locations

Bradley Brummett, PhD, ABN

Board Certified in Clinical Neuropsychology, he/him

After completing the form, click the SUBMIT QUESTIONNAIRE button below.