Please complete only appropriate paperwork for your concern listed below and upload clear pictures of the front and back of your insurance card(s). Click herefor more information on insurance and billing.
Once we have received ALLNECESSARY documents, our clinical team will review your paperwork and we will be in touch within 2 weeks to let you know the next steps and timeline. Please note: we do not have the capacity to respond to questions about paperwork status.
Step One: Upload Insurance Card
Insurance Card
If you intend to use insurance for any services, please upload clear pictures of FRONT and BACK of the client’s insurance card(s). Click herefor more information on insurance and billing.
Step Two: Complete these THREE documents. These are necessary documents for ALL services. We cannot schedule an appointment without these documents.
For ALL services
FOR ALL CONSULTATIONS, ASSESSMENTS, & OTHER SERVICES
Please complete ALL paperwork listed below and upload clear pictures of the front and back of your insurance card(s).
Once we have received all necessary documents, our clinical team will review your paperwork and we will be in touch within 2 weeks to let you know the next steps and timeline.
Step Three: In addition to the above necessary documents, please complete ONE of from this list below depending on service(s) you are requesting. DO NOT COMPLETE ALL FORMS. ONLY complete the forms specific to your concern.
Consultation & Assessment Services
If you are requesting a consultation or any assessment services, Please complete the most applicable ONE of the following questionnaires IN ADDITION to the above necessary documents. Please also upload important documents (see below) to be included in your comprehensive review and consultation.
PARENT Questionnaire: For children under the age of 18 or still enrolled in high school.
ADULT Questionnaire: For individuals 18 and over (and not a high school student).
Please upload scanned copies of other important documents to be included in your comprehensive review and consultation (e.g., IEP, 504 Plan, previous psych testing, hospital discharge summaries, neurological reports, etc.). Each document must be a single file- please do not upload large documents one page at a time.
Adult Cognitive Health & Memory Center (Ages 45+ only for concerns such as dementia, cognitive/memory decline, etc.)
If you are requesting services through the Cognitive Health & Memory Center for ages 45+ please complete these forms IN ADDITION to the above necessary documentation. *Please note: we do NOT accept Medicare.
If you are requesting a REACH partnership with Hampshire and Franklin Counties evaluation, please complete the form below IN ADDITION to the above necessary documentation.
If you are requesting a consultation or any educational assessment services, Please complete the most applicable ONE of the following questionnaires IN ADDITION to the above necessary documents. Please also upload important documents (see below) and have a teacher complete the information form to be included in your comprehensive review and consultation.
PARENT Questionnaire: For children under the age of 18 or still enrolled in high school.
ADULT Questionnaire: For individuals 18 and over (and not a high school student).
Please upload scanned copies of other important documents to be included in your comprehensive review and consultation (e.g., IEP, 504 Plan, previous psych testing, hospital discharge summaries, neurological reports, etc.). Each document must be a single file- please do not upload large documents one page at a time.
If you are requesting services regarding an educational or academic concern, this form is recommended and helpful for questions regarding academics and learning disabilities.
Prior to the consultation appointment please have the client’s vision and hearing screened by their medical provider.
Neurological Injuries
If either you or your child has had any neurological injuries that have been treated, please have your medical provider clear you for testing, and provide us with any reports summarizing the injury and treatment.
