Request Appointment – Houston Neuropsychology Associates

Referring healthcare providers, patients, and/or patient family members may use the form below to request an appointment. The information will be sent securely to our office. A member of our staff will then contact you or the patient to schedule the appointment.

If you have already called our office for an appointment, please do not fill out this form, as doing so may delay scheduling of your appointment.

Patient's Full Name*
First Middle Last
Referral Source*
Who referred you (or the patient) to us?
First Last
Reason for Evaluation*
Please select the primary reason for seeking evaluation.
Explanation*
You selected "other" as the reason for evaluation. Please describe the issue here.
Patient's Date of Birth*
MM slash DD slash YYYY
Contact Information
Patient's Mailing Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone Number*
Please enter the preferred contact number.
Secondary Phone Number*
Please enter a secondary phone number.
Permission to Leave Message*
May we leave a message when calling if we are unable to reach you directly?
Patient's Email Address*
Enter Email Confirm Email
Method of Payment*
Please indicate if you intend to use health insurance or will be paying out-of-pocket.
Insurance Information
Name of Primary Insurance Company*
Other Insurance Company*
Please list the insurance company name here.
Full Name of Subscriber*
First Middle Last
Subscriber's Date of Birth*
MM slash DD slash YYYY
Subscriber's ID Number*
Subscriber's Group Number*
Subscriber's Employer Name*
Insurance Company Phone Number*
This number is usually listed on the back of the card.
Additional Information*
Is this request for evaluation related in any way to an actual or possible lawsuit, legal matter, disability claim, or accommodations in school?
Details*
Please provide details on your answer to the above question.
Email
This field is for validation purposes and should be left unchanged.

Contact Information

Insurance Information