New Client Intake Questionnaire

Emergency Assistance

If this is an emergency, call:

Crisis Line: (413) 586-5555
911
Or Go to Your Nearest ER

Client Information

First name

Last name

Primary phone number

Secondary phone number (if any)

Email address

Date of birth

Street Address

City, State, and Zip Code

Last 4 digits of your SS#

Insurance Information

Name of your insurance company and plan

Primary insurance member ID number

Secondary insurance (if any)

Secondary insurance member ID number (if any)

Primary subscriber to insurance

This is the primary person listed on the insurance.

Primary subscriber date of birth

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. Next, Dr. Brummett's staff will verify your benefits. You will then be contacted to schedule an appointment.

Electronic Signature

Signed

Type your full name

Today's date

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Dr. Bradley Brummett

Clinical Neuropsychologist

Bradley Brummett, PhD, is a clinical neuropsychologist with nearly 20 years of experience. His areas of expertise include traumatic brain injury (TBI), dementias (e.g., Alzheimer's disease), multiple sclerosis (MS), Lyme disease, cerebrovascular accident/stroke, disordered attention (ADD/ADHD), 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
ncsnoho.com
2 Bay Road, Suite 202, Hadley, MA, 01035, USA