Online Forms using IntakeQ
Completing your registration forms online streamlines our intake process and saves time over filling out traditional forms on a clipboard. IntakeQ is a secure, HIPAA-compliant electronic intake platform. Simply click on the links below as directed by your provider or RIW coordinator and follow the instructions.
New Patient Registration Forms
This bundle of forms will include our standard Registration Form, our Notice of Privacy Practices, and Financial policy. You can also upload an image of your insurance card and/or ID. If you are scheduled for telemedicine, please also complete the telemedicine consent form.
Program Specific Forms
Brain Injury Rehabilitation Program (BIRP)
Structured Intensive Multidisciplinary Program (SIMP)
- Adult Neuropsych Intake
- Pediatric Neuropsych Intake
- Informed Consent
Other New Patient Evaluations
If you prefer, our forms are also available in PDF format. To view these files, you must have Acrobat Reader installed on your computer. To download the latest version for free, please click here.
Please print the following forms, and complete prior to your first appointment. If you are unable to complete the forms in advance, please allow extra time before your scheduled appointment to complete the forms in the clinic.
- New Patient Registration Form
- New Patient Financial Agreement
- Patient Information and Financial Policy
- New Patient Questionnaire
- Notice of Privacy Practices
- Notice of Privacy Practices – Acknowledgement
Workers’ Compensation Forms
Pain Management Program
Brain Injury Rehabilitation Program
- Brain Injury Rehabilitation Program Orientation Guide
- Demographics and Injury Characteristics of Persons Served
- Treatment Program Outcomes