Forms

The following forms are the basic forms that you will need to complete prior to your scheduled appointment.

• Intake Form – Child
• Intake Form – Adult
• Background Information Form – Child
• Background Information Form – Adult
• Background Information Form – Prior Patient Only
• Practice Privacy Act
• Parent/Guardian Agreement Not to Use Minor’s Neuropsychological Information/Records in Custody Litigation
• Informed Consent Form-Testing
• Authorization to Communicate via Email

Please print and complete this form if you would like me to communicate with any other professionals:

• Dual Authorization to Release Info

Please print and complete this form if you have scheduled a school observation:

• Authorization for School Visit

Please print and complete this form if you would like Dr. Lurie to automatically recharge your credit card the payments due on the two days of the testing and feedback session. The information from your credit card will be collected when you make your initial deposit. If you are late for an appointment, an additional fee will be charged for any time needed to complete the assessment (15 min or more).

• Authorization to Recharge Credit Card

Please review this Good Faith Estimate Information:

• Good Faith Estimate Information