If you're a first-time client, please review and complete the following forms, bring them to your first session. If you have set up a consultation via phone, please fax back your forms to FAX 866.373.8006.
- Credit Card Authorization Form (required to be faxed in advance of initial appointment for all clients, incl. cash paying clients)
- Cancellation Policy Form (required by fax in advance of initial appointment)
- Insurance Information Form and Third Party Payment Information (required for all clients requesting SUPERBILLS for insurance submission, all clients who are requesting payment from a source other than themselves)
Use this form is you wish to authorize a release of information or coordinate information with another medical or legal entity, such as a medical doctor, medical laboratory, psychiatrist, endochrinologist, or attorney. This release is specific to persons, agencies, medical entities, and to obtain test results (of any kind) and attorneys. Please fill one out for each entity you wish to release information to or from.
Required Symptom Assessment Forms below may also be found @ BrainWellnessPRO.com
Required Symptom Assessment Forms below may also be found @ BrainWellnessPRO.com
- Adult Neurotransmitter and Health Assessment Questionnaire (NTAF)
- Child Neurotransmitter and Nutrition Assessment Questionnaire (to be filled out by parents)
- Symptom Assessment (initial and follow up assessment form)
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