New Patient Intake Form

We are Expanding!  As our new providers wait for insurance credentialing, we have a limited number of Private Pay Neuropsychological Evaluation appointments available with less than a month wait.  Saturday Private Pay appointments are also available for both Early Childhood Evaluations (under age 4) and Neuropsychological Evaluations (ages 4-6 only).  Please see our Fee Schedule for pricing and indicate in any "Other" Section on your Appointment Request form that you would like a Private Pay appointment. Unfortunately, we are unable to see children with Medical Assistance for any Private Pay Services.

Please be aware that we are currently scheduling neuropsychological evaluations 6-12 months out, depending on your child’s specific needs and insurance. Every child eligible for evaluation will be offered an appointment.  

We ask that you only submit this form if you have decided that you would like to be scheduled for an evaluation despite our wait.

 If you are seeking therapy, please be aware that due to our extensive waitlist, we are only accepting internal therapy referrals (i.e. children who have completed an evaluation at CPN) AND children seeking Athletic Performance/Sports Psychology Services. We apologize for an inconvenience this may cause.