What Should I Bring?
What should I bring to the intial intake appointment?
- Printed and completed new patient forms
- Copies of previous evaluations, medical records, school records, and/or therapeutic records
What should I bring to the evaluation appointment?
- Any additionally requested records, rating forms, or questionnaires
- Preferred snacks for your child to eat
- Your child should wear or bring with them their prescribed contact lens/glasses, hearing aids, or any other equipment
- Your child should wear comfortable clothing
- Your child should take their prescribed medication, unless otherwise previously discussed
What should I bring to the follow-up appointment?
- Parents are welcome to bring any preferred persons of support with them
ALL patients need to complete and sign the following forms prior to their first appointment:
- CDNC Patient Registration Form
- CDNC Patient Consent Form
- CDNC Notice of Privacy Practices Form
- CDNC Telepsychology Informed Consent Form
- CDNC Financial Agreement Form
- CDNC Email Communication Agreement Form
- CDNC Internet Policy Form
- CDNC Patient & Family Rights & Responsibilities Form
NEW patients should complete the Pediatric Neurodevelopmental History Form:
- CDNC Pediatric Neurodevelopmental History Form
RETURNING patients who have been previously seen by Dr. Jensen for a Neuropsychological evaluation should complete the Re-evaluation History Form:
- CDNC Re-Eval History Form
CDNC is a private pay clinic, meaning that payment is expected at the time service is provided. We are, however, insurance friendly and will provide families a detailed invoice (superbill) that can be submitted by families to their insurance for reimbursement. This will include dates of service, procedure codes, and diagnostic codes.
Neuropsychological evaluations may be a covered service with many insurance companies, depending upon your specific plan. Please check with your insurance provider at the outset of treatment to ensure that you are covered for your treatment, including for specific diagnoses of concern, if you plan to use your out-of-network benefits.
It is the patient’s responsibility to check their insurance plan coverage. To avoid unpleasant surprises, we strongly encourage our patients to carefully research the specific provisions of their health insurance coverage.
You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including neuropsychological evaluations, psychological evaluations, and psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your rights to a Good Faith Estimate, visit www.cms.gov/nosurprises
A Good Faith Estimate of the range of costs possible will be provided to you based on the scope of services requested.