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. He will take a single case agreement. This may require you calling and working in conjunction with the UCSC insurance department and/or Anthem Blue Cross. Call your insurance company for details.

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FORMS for ALL Patients:

Informed Consent Testing 7.29.17 (Required for a Psych Evaluation Test)

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