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Neuropsychological Testing
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Autism Testing
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About
Blog
Assessment Services
Neuropsychological Testing
Psychological And Psychiatric Testing
Psycho-Educational Testing
Autism Testing
Psychiatric Fitness-For-Duty Examination (FFDE)
Forensics
Medical Clearance
Disorder We Diagnose
ADD and ADHD
Autism
Learning Disabilities
Depression
Anxiety
Bipolar Disorder
Developmental Delays
Speech / Language Delays
Behavior Issues
Memory Issues
PTSD
Forensics & Legal
Attorneys and Law Firms
Individuals
Payment Options
Insurance
Self-Pay
FAQ
Media
About
Blog
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Comprehend the Mind -
a leader in neuropsychological evaluations in NYC
(conveniently located in Forest Hills, Queens)
Fill out the form below or simply call us at
718-441-0166
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Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
*Required fields
ABOUT THE PATIENT
PATIENT'S FIRST NAME
*
PATIENT'S LAST NAME
*
RELATIONSHIP TO PATIENT
*
SELF
OTHER (PLEASE SPECIFY ON THE NEXT FIELD)
RELATIONSHIP TO PATIENT: OTHER (*IF APPLICABLE)
GENDER / PRONOUNS
*
PATIENT'S DATE OF BIRTH
*
BRIEF REASON FOR REFERRAL/EVALUATION
*
CONTACT INFORMATION
PHONE NUMBER
*
EMAIL ADDRESS
*
WILL YOU USE INSURANCE OR SELF-PAY?
*
INSURANCE
SELF-PAY
INSURANCE INFORMATION (
OPTIONAL
)
INSURANCE COMPANY AND PLAN
INSURANCE MEMBER ID
INSURANCE SUBSCRIBER'S NAME (LAST, FIRST)
RELATIONSHIP TO PATIENT
SUBSCRIBER'S DATE OF BIRTH
GENDER INFORMATION (
OPTIONAL
)
Layout NAME USE
HOW DID YOU HEAR ABOUT US?
ADDITIONAL COMMENTS
Submit