Download Intake Paperwork.
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Download Printable Script
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Intake Checklist:
The client’s case manager and legal guardian are required to be present at intake. Please send all requested documents and completed paperwork to Life Skills Village TWO DAYS BEFORE your scheduled appointment:
1. Client Registration form, including:
3. ER Records
4. Hospital records
5. List of all treating physicians (primary, neurology, PM&R, psychiatrist, etc.)
6. List of all providers involved in your care (psychologists, behaviorists, vocational, recreational, occupational, speech-language pathologists, physical therapists)
7. Current insurance information
8. State issued identification (to be scanned at appointment)
9. Insurance cards (to be scanned at appointment)
10. Signed prescription from physician or referral from a psychologist
11. Copies of any brain imagining
12. Notes from prescribing physician
13. Signed Assignment of Benefits form
14. Signed HIPAA Authorization and Release forms
15. Current neuropsychological report (completed within the last 12 months)
16. Attorney contact information
17. Transportation contact information
18. If TBI is related to a motor vehicle accident, we will also require a copy of the
Please note that failure to have these documents completed and to Life Skills Village within two days of you appointment may result in your intake/assessments being rescheduled.
1. Client Registration form, including:
- Physical address where client currently resides
- Contact information for all case managers (both internal and external)
3. ER Records
4. Hospital records
5. List of all treating physicians (primary, neurology, PM&R, psychiatrist, etc.)
6. List of all providers involved in your care (psychologists, behaviorists, vocational, recreational, occupational, speech-language pathologists, physical therapists)
7. Current insurance information
8. State issued identification (to be scanned at appointment)
9. Insurance cards (to be scanned at appointment)
10. Signed prescription from physician or referral from a psychologist
11. Copies of any brain imagining
12. Notes from prescribing physician
13. Signed Assignment of Benefits form
14. Signed HIPAA Authorization and Release forms
15. Current neuropsychological report (completed within the last 12 months)
16. Attorney contact information
17. Transportation contact information
18. If TBI is related to a motor vehicle accident, we will also require a copy of the
- Police Report
- EMS Records
Please note that failure to have these documents completed and to Life Skills Village within two days of you appointment may result in your intake/assessments being rescheduled.