Patient Forms

Please print and sign all documents required and bring them with you to your first appointment.

Forms Required

1. Symptom Measure Form - Please print and complete the appropriate form below.
   Self-Rated Level 1 Cross-Cutting Symptom Measure - Adult
   OR
   Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure - Child Age 6-17
   
2. Patient Intake Form (PDF Fill-in Form, revised 08.09.2022) Use the FREE Adobe Reader to fill in form fields. After completion, please print, sign and bring this form to your first appointment.
3. HIPPA Notice of Privacy (PDF document, revised 08.05.2022) Please read.
4. HIPPA Acknowledgement of Receipt of Notice of Privacy (PDF document, revised 08.05.2022) Please print, sign and bring this form to your first appointment.
5. Description of Testing Services (PDF document, 08.08.2022)  Please print, complete form, sign and bring it to your appointment.

Dr. Eisenbeiss will provide billing information for you to submit to your insurance company.  Dr. Eisenbeiss no longer accepts insurance. Dr. Eisenbeiss will be able to make an appointment with you  within 2 weeks.  No waiting for weeks or months for testing.  Dr. Eisenbeiss would be considered an out-of-network provider. Your insurance company should provide you information on what they are able to pay you for psychological/neuropsychological services.  Your insurance company will reimburse directly to you all payments.  Dr. Eisenbeiss will accept cash or credit cards but no checks.  All services will need to be paid for upfront.  Dr. Eisenbeiss’s fee for the first 1/2 initial interview will be $125.00.  After the first diagnostic interview he can tell you what the fee will be for all testing.  Depending on what type testing is needed then the testing fee may range from $875.00 to $2375.00.