Name of person completing this form: *

Contact Information

Address:

Email: *

Main Phone: *

Second Phone:

Preferred means of contact: * Main Phone Second Phone Email

Client Information

(Please provide the following information, if applicable, for the individual for whom services are being sought.)

Individual For Who Services Are Being Sought If Different From Above: *

If applicable, is the person completing this form a parent or legal guardian of the person beginning the program? * Yes No

Age *

Date of Birth

Present Insurance Provider/Plan:

Previous Evaluations/Assessments and results:

Current Medications Taken and Dosages:

Current Medication Provider:

Previous Medications Taken:

Previous and Present Counseling/Therapy (Dates and Providers):

Substance Abuse History:

Current Medical/Physical Issues:

Other Pertinent Information:

HIPAA-Related Service Policies

Prior to the beginning of any treatment at Neurocore, you (or a legal guardian) will be required to sign a Training Agreement/Treatment Consent Form. Should you wish to have any information related to services obtained at Neurocore shared with other health care providers, you (or a legal guardian) will be required to complete an Authorization to Release Information Form.

Contact Information:
neurocore
3790 30th St.
Grandville, MI 49418
1.800.600.4096

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