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

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.

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.psychologytoday.com/us/therapists/bradley-brummett-phd-scarsdale-ny/330414
330414

New Client Intake Questionnaire

Office Locations

Client 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.