The first step in getting an assessment or pursuing other services is to contact Dr. Imber. If you decide together to schedule an appointment, you will receive a Welcome Letter with the specifics of your appointment. The next step is to complete and transmit the paperwork that will help her to plan your interview, evaluation and/or treatment. This information is very important for her to receive before you meet in person, so that she is familiar with your situation and can make the best use of your time together.
Cogmed Users Only:If you’re looking for the Cogmed Intake Questionnaire, please click here to download the adult form or here to download the child form (for Users under age 18). Prospective Cogmed users do not need to fill out the other paperwork on this site.
Otherwise, if you are new to this practice and are seeking assessment or therapy, you’ll want to download a complete packet of forms below. You can also click on the names of the individual forms, if you’d prefer to download them one at a time or if you do not need the whole packet.
If you have trouble downloading the whole packet, try clicking on the individual forms and downloading them one at a time instead.
You’ll find brief instructions next to the name of each form. You will need Adobe Reader, free software that lets you read PDF files, in order to view these; you can download it here.
Forms 4, 5, and 6 are required to help Dr. Imber prepare for your appointment; Form 7 is optional.
You should also see this useful page about preparing for your evaluation.
Q: How do I choose between the Adult and Pediatric Packets?
A: Download the Adult Forms if you are completing them for yourself (or for an adult parent or spouse). Download the Pediatric Forms if you are completing them for your child (youngster, adolescent, or young adult). The main difference is the History Form, which solicits more detailed information about early years and development on the Pediatric Forms. (Most adults do not have access to this level of detail about their childhood.)
New Patient Packets:
These packets are saved as Adobe PDF portfolios, files that contain multiple documents. When you click on a portfolio file, it will open in Acrobat Reader and you’ll see all the forms it contains. Choose one to look at and then use the little arrows on the upper left-hand-side of the screen to navigate to the previous or next document. This way, you can view the forms one at a time and just print the pages you need.
Download the Complete Adult Packet here
Download the Complete Pediatric Packet here
These packets are designed to provide “one-stop shopping” for new clients. Here’s what’s included, and what to do with it; you can click on the individual forms if you prefer to download them one-at-a-time.
- FAQ (2 pages): A shortened version of the Frequently-Asked Questions list found on the website. Just for your information.
- Directions (2 pages): Printable directions to the office. Just for your information.
- Privacy Notice (5 pages): Important information about how your private information is handled at this practice. Please be sure that you have read the most up-to-date version of this form, last updated 07/2017.
- Insurance/New Patient Form (1 page): Please complete this even if you are not planning to use your insurance for this evaluation. Fill this out and fax it to Dr. Imber at 1-888-974-0260, or send it via postal mail.
- Adult History Form or Pediatric History Form (6 pages for Adults; 8 pages for Pediatric): Provides important background information that will help Dr. Imber plan the interview and evaluation. Fill this out and fax it to Dr. Imber at 1-888-974-0260, or send it via postal mail.
- Physician Referral Form (1 page): This important form documents the medical necessity for the evaluation and helps Dr. Imber understand your referring provider’s questions. If you are planning to use your insurance for this evaluation, ask your referring doctor (usually a PCP) to fill this out and fax it to Dr. Imber at 1-888-974-0260.
- Authorization Form (2 pages): This two-way authorization form permits Dr. Imber to exchange information about your case with anyone you designate. Please complete both pages, and put only one entity in each box (e.g., neurologist in box 1, psychiatrist in box 2, spouse in box 3). Important: If your adult child (age 18 or over) is having an evaluation, or if you are an adult who wishes Dr. Imber to share and receive information from a spouse, parent, or adult child, this form is required. If it is not completed, Dr. Imber will only communicate directly with the adult patient. Dr. Imber will not communicate about details of your case with anyone without an authorization, except when required as detailed in the Privacy Notice.
If you have any questions about any of these documents, please call the office at 617-487-8910.