Client Documents

In an effort to save time and to ensure that you have the maximum amount of time interacting with your clinician during your visit, we have made it easy to print and fill out your new client paperwork ahead of time. This way you don’t have to spend time filling out forms in the waiting room.

Please print and fill out the following 4 forms in preparation for your intake appointment:

Consent FormPlease print two copies; one for your signature and one for your records. Please read and sign one of the copies and bring it with you to your first visit.

Intake DocumentPlease answer each question to the best of your ability. You may email, fax, or bring a copy of the completed form to your intake appointment

Office Policies and ProceduresPlease print two copies; one for your signature and one for your records. Please read and sign one of the copies and bring it with you to your first appointment.

Notice of Information Practices http://www.nchouston.org/wp-content/and Privacy StatementPlease print two copies; one for your signature and one for your records. Please read and sign one of the copies and bring it with you to your first appointment.

Please print, review, and sign the following form if you are scheduled for a qEEG:

qEEG Checklist and ConsentPlease print two copies; one for your signature and one for your records. Please read and sign one of the copies and bring it with you to your qEEG appointment.

Other documents that might be useful: 

CPT Codes for Insurance BillingThese codes are used by insurance companies to determine the procedure for reimbursement. We encourage all of our clients to check with their insurance company to determine eligibility for reimbursement.

Authorization to Release InformationPrint, fill out, and sign if you would like to authorize the release of your client information to a third party.

Email us at [email protected] if you experience technical issues.