All Things Neuro Intake Form

All Things Neuro Intake Form
State*
Referring Medical Provider:
Referring Provider Phone Number:
Format: (000) 000-0000.
Referring Provider Email:
Law Office Name*
Law Office's Phone Number*
Format: (000) 000-0000.
Law Office's Email*
PATIENT INFORMATION
Patient Full Name*

First NameLast Name
Email
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date of Injury*

MonthDayYear
Patient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
MVC (motor vehicle collision)Slip and FallOther
EnglishSpanishKoreanVietnameseFrenchPortugeseChineseHindiOther
Important Note on IME Requests

Independent Medical Examinations (IMEs) are not required for all referrals. Please only check an IME option if the referring provider has specifically requested an IME for legal or case-related purposes. If you are seeking routine treatment or evaluation (e.g., TBI, Neuropsych, or related care), do not select an IME.
Psych Pain IMENeurological IMENeuropsychological IMEPsychological IMEPsychiatric IMEOrthopain IME
Pain Psychology IME

A pain psychology IME is performed by a licensed clinical psychologist with expertise in chronic pain and psychosocial factors affecting recovery. The evaluation includes a detailed clinical interview, medical and psychological records review, and validated pain-related assessments (e.g., pain perception, coping strategies, mood, sleep, and quality of life). The psychologist evaluates for symptom validity, pain catastrophizing, kinesiophobia (fear of movement), and the impact of psychological factors such as depression, anxiety, trauma, or somatization on reported pain.

Findings support differential diagnosis, clarify the relationship between psychological factors and pain presentation, assess functional limitations (work, home, activities of daily living), and provide defensible recommendations for treatment, rehabilitation, and case management.

Note: Pricing and fee schedule will be provided prior to scheduling.
Neurological IME
A board-certified neurologist conducts a comprehensive evaluation of the central and peripheral nervous system. Includes medical record review, targeted neurological exam, correlation with diagnostic testing, causation/apportionment analysis (when requested), functional capacity and work status, and treatment recommendations.

Note: Pricing and fee schedule will be provided prior to scheduling.
Neuropsychological IME
A PhD/PsyD neuropsychologist performs a standardized battery assessing attention, memory, processing speed, executive function, and symptom validity/effort. Includes full records review, differential diagnosis, functional impact analysis (home/work/driving), and clear, defensible recommendations.

Note: Pricing and fee schedule will be provided prior to scheduling.
Psychological IME
A clinical psychologist evaluates mental health conditions with interview and validated measures as indicated. Includes DSM-5 diagnostic impressions, risk and functional impact assessment, and evidence-based treatment recommendations.

Note: Pricing and fee schedule will be provided prior to scheduling.
Psychiatric IME
A board-certified psychiatrist conducts a medical-psychiatric evaluation including mental status exam, differential diagnosis, medication considerations, and causation/apportionment when requested. Addresses work capacity and treatment planning.

Note: Pricing and fee schedule will be provided prior to scheduling.
Orthopedic/Pain IME (aka “Orthopain IME”)
An orthopedic or interventional pain specialist evaluates musculoskeletal injuries and pain generators. Includes records and imaging review, focused physical exam, procedural/interventional options, work restrictions/MMI, and impairment considerations as appropriate.

Note: Pricing and fee schedule will be provided prior to scheduling.
Reason or Notes*
Balance problemsBlurred visionConfusionDifficulty concentratingDifficulty rememberingDizzinessDon’t feel normalDon’t feel rightDrowsinessFatigue or low energyFeeling like in a fogFeeling slowed downHeadacheIrritableLight sensitivityMore emotionalNauseaNeck painNervous or anxiousPressure in headSadSound sensitivityTrouble falling asleepVomitingOther
Corresponding Medical Records

Cancelof
Additional Comments
Should be Empty:

All Things Neuro Intake Form

PATIENT INFORMATION