Street Address: 2140 41st Avenue, Suite 200B, Capitola, CA 95010
Main Telephone Number: (321) 208-1554

              Office Manager Telephone Number: 321-298-8668
              E-Mail Address: gerardphd@hipaamail.us
              Fax Number: (831) 325-0125

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.

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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.

  Content Copyright 2014. All Rights Reserved: Gerard Chambers Psy.D., Ph.D. -- 2140 41st Avenue, Suite 200B, Capitola, CA 95010 -- Phone: (321) 208-1554