Unity Neurobehavioral Health, A Psychological Corporation

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

State

Select the state you live in

Reason for care

What type of service are you seeking?

Neuropsychological Evaluation (e.g., memory concerns, dementia, neurological conditions, or traumatic brain injury) Psychological Evaluation (e.g., diagnostic clarification, emotional or behavioral concerns, or complex clinical presentations) Attention-Deficit/Hyperactivity Disorder (ADHD) Evaluation Psychotherapy (e.g., therapy for emotional, behavioral, or adjustment concerns) Executive Functioning Training (EFT; e.g., support with organization, planning, time management, task initiation, and self-monitoring) Interdisciplinary Consultation (e.g., collaboration with healthcare, educational, or other professionals regarding diagnostic or treatment planning needs) Workshop Presentation (e.g., professional education, community training, or psychoeducational presentations) Clinical Supervision (e.g., supervision, consultation, and professional development for psychology trainees and clinicians) Other

What is the primary question or concern for seeking care?

For neuropsychological or psychological assessments, what is the primary question you hope the evaluation will answer?

Limited to 600 characters

Is this evaluation being requested for a legal, forensic, disability, workers’ compensation, custody, immigration, academic accommodation, or other third-party purpose?

Administrative

Referral source

How were you referred to our practice?

Self-Referred Healthcare provider School or educational professional Attorney or legal professional Other

Is there anything else you would like us to know that may help us understand your inquiry or determine how we can best assist you?

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Who are you contacting us about?

Self My Child/Dependent A Family Member Other

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Complete this section only if you plan to use insurance benefits. If you will be paying out of pocket, you may leave this section blank. Insurance Company: Member ID: Group Number: Insurance Address: Information Listed on Insurance Card Name: Date of Birth: Sex Listed on Policy: Are you the policyholder? Yes / No If you are not the policyholder: Policyholder Name: Date of Birth: Sex Listed on Policy: Relationship to Client:

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Insurance card upload

Upload a photo of your insurance card

Client Preferences

Is there any additional information about your concerns, history, or current circumstances that would be helpful for us to know before scheduling?

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.