Patient Forms

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)

Printable Forms

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.

Workers’ Compensation Forms

Pain Management Program

Brain Injury Rehabilitation Program

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