Forms to Schedule Tutoring or
Cognitive Retraining

Please complete the following documents and return them to our office prior to (or at the time of) your appointment: 

CLIENT INFORMATION SHEET

Please complete all sections that apply to the client referred for services.

• Client Intake form (Children and Students) PDF format
• Client Intake form (Children and Students) Word .doc
   
• Adult Intake Form PDF format

• Adult Intake Form Word .doc
   

PARENT INPUT FORM

Parents should complete this form based upon their observations of the child at home and the feedback they have received about the child from teachers.

• Parent Input form PDF format
• Parent Input form Word .doc
   

EDUCATIONAL RECORDS

Please make a copy of the client’s educational records and put them in chronological order from the oldest (top) to the current (bottom).

FEE POLICY

Please sign, date and return these forms to the office at the time of your first appointment. If you would like to have copies for your records, we will provide them.

• Fee Policy PDF format
• Fee Policy Word .doc
   

CONSENT FORMS

Please sign, date and return this form to the office at the time of your first appointment. If you would like to have a copy for your records, we will provide it.

• HIPAA Consent Form PDF format
• HIPAA Consent Form Word .doc
   
• Notice of Privacy Practices PDF format
• Notice of Privacy Practices Word .doc
   

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Last modified: January 03, 2008