Psych Evaluation Test Forms Details
PSYCH EVALUATION TEST FORMS PAGE
UCSC Students: Dr. Chambers does not take your insurance. However, you will receive a check for all services he provides to you after you pay the contracted rate in full. Those interested in the details should contact our offices. This does require a large out of pocket expense that will be refunded to you by Anthem Blue Cross within 3-6 Weeks.
FORMS for ALL Patients:
Informed Consent Testing 8.29.16 (Required for a Psych Evaluation Test)
Telemed Informed Consent 6.25.15 (Telelmed Informed Consent)
HIPAA Word Final 5.9.15 (Required Psych Evaluation Test)
Intake Form 5.15.15 (Optional, HIGHLY Suggested for Children)
Authorization of Release 6.25.15 (For all Releases of Information)
UCSC HARDSHIP LETTER 6.25.15 (For Students Needing Financial Help From the School) *You will need the funds prior to the appointment. It usually takes about 2 weeks.