New Client Intake Questionnaire

Emergency Assistance

If this is an emergency, call:

Crisis Line: (413) 586-5555
911
Or go to the Emergency Room

Assessment ID (OFFICE USE ONLY): ____________________________________

Client Information

First name

Last name

Primary phone number

Pronouns

Race and Ethnicity

Birth Sex and Gender Identity

Email address

Date of birth

Street Address

City, State, and Zip Code

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, (if you are using insurance) Dr. Brummett's staff will verify your benefits. You will then be contacted to schedule an appointment.

Name of person completing this form

Today's date

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

Your information will be encrypted.

Dr. Bradley Brummett

Clinical Neuropsychologist, he/him

Bradley Brummett, PhD, is a clinical neuropsychologist with 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, 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 201, Hadley, MA, 01035, USA

New Client Intake Questionnaire

Emergency Assistance

Assessment ID (OFFICE USE ONLY): ____________________________________

Client Information

Insurance Information

Referral and Brief History

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

Emergency Assistance

Dr. Bradley Brummett

Clinical Neuropsychologist, he/him

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