Patient Information

HIPAA

You can read and download our HIPAA “Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information”. (If your computer doesn’t have Adobe’s free Adobe Reader, click here to download and install it.)

You can also acknowledge that you reviewed and understand that form:

Electronic Acknowledgement Form
I electronically acknowledge that I have reviewed and understand CNS's "Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information" form and that, if I wish to keep a copy, I have downloaded and saved the PDF version of the form.
Name
First Last
Date

Directions to Our Offices

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Patient Information Form

If you want to become a patient at CNS or would like to schedule a consultation, completing and sending the following online Patient Information Form will save you time when you come to the office.

Your Information
Name
First Last
Email
Telephone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Your Physician's Information
Primary Care Physician
Physician's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Information
Insurance Company
Insurance Telephone
Policy Number
Group Number
Policyholder
Referral Question
Who referred you?
Please check all services that you are requesting:
- Neuropsychological Evaluation
- Psychological Evaluation
- Neuropsychological Rehabilitation
- Psychotherapy
- Rehabilitative Psychotherapy
- Consultation
Reason for services requested?

Comprehensive Neuropsychological Services, P.C.
1095 South Main St.
Cheshire, CT 06410

Telephone: Local 203-271-3809, Toll-Free 877-788-7822
Fax: 203-272-6968
Email: cns@clinicalneuropsych.com

Electronic Acknowledgement Form

Your Information

Your Physician's Information

Insurance Information

Referral Question