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2025 Neurology Medical Symposium

Clinical Psychology Intake Form

Patient’s Legal Name *

First

Last

Patient’s Preferred Name *

Patient’s Date of Birth *

Patient’s Social Security Number

Patient’s Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

DEMOGRAPHIC INFORMATION

Patient’s Ethnicity

Patient’s Race

Patient’s Primary Language

Patient’s Birth Sex

Patient’s Gender Identity

RESPONDENT INFORMATION

***This section is for patients under 18-years-old or for any patient that has a legal guardian***

Name of Parent/Legal Guardian *

First

Last

Relationship to the Patient

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Are you involved in any litigation (suing someone and/or being sued)?

If YES, please elaborate

REFERRAL INFORMATION

*** Please note a provider referral is not required***

Referral Source

Primary Physician
Mental Health Professional
School Personnel
Self
Other

Name of Referral Source

Referral Phone

Reason for Referral

TESTING SERVICES

***Please select the Testing Service that you are interested in pursuing***

Checkboxes

Attention-Deficit/Hyperactivity Disorder (ADHD) ($1,200-$1,900) ADHD evaluations are available for individuals 4 years old through adulthood
Autism Spectrum Disorder ($1,460-$3,075) ASD evaluations are available for individuals 18 months through adulthood
IQ Only ($650) IQ testing is available for individual ages 6 through adulthood
OPWDD: Concerns for Intellectual Disability (without ASD) ($800-$1,050) We offer comprehensive psychological evaluations to support eligibility determination for the New York State Office for People With Developmental Disabilities (OPWDD). These evaluations are designed to identify qualifying conditions such as an Intellectual Disability and provide the documentation to support eligibility for the New York State Office for People With Developmental Disabilities (OPWDD). Evaluations for OPWDD, without testing for Autism Spectrum Disorder, are available for individuals ages 6 through adulthood.
Comprehensive Psychological Evaluation (Fees depend on the type of evaluation and testing needed) We offer an all-encompassing evaluation for individuals seeking a clearer understanding of complex or overlapping symptoms. Evaluations may include tests of cognitive ability, executive functioning, attention, adaptive skills, as well as personality and social functioning, emotions, and behaviors – depending on the individual’s presenting concerns. This types of evaluation is available for individuals ages 13 through adulthood.
Evaluation for Educational and Testing Accommodations (Fees depend on the type of evaluation and testing needed) We offer psychological evaluations to support accommodations in school and college settings as well as for high-stakes testing (e.g., GRE, LSAT, MCAT, etc.). These assessments focus on identifying conditions - such as ADHD, anxiety, or processing speed concerns – that may affect academic and testing performance. Please note: while we do not offer achievement testing and therefore cannot diagnose specific learning disorders such as Dyslexia, Dyscalculia, or Dysgraphia, we tailor our evaluations to meet current documentation standards and provide clear clinical justification for any requested accommodations.

Describe the presenting concerns and why you are interested in this type of testing service

Goals for the evaluation

PRIVATE PAY

Check the following to continue. *

I understand that this is a private pay service, and the total cost will be discussed following the initial consultation(s)
I understand that the cost of the initial consult is $250 per appointment (two initial consultations are required for pediatric patients, therefore $500 total). This payment is due prior to attending the appointment.
I understand that the total cost of the evaluation will be discussed with the provider following the initial consultation(s), and the payment for the initial consult(s) will be included in the total cost of service.

Referral in

If you have questions regarding payment and pricing, please call 716-961-9204 or visit our website.

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