New Client Referral

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Once the following information is received, your client can expect a call within 24 hours to schedule the appropriate testing or consultation. You may also submit a new client referral via fax to 561-258-8154.

Client Referral Information Required:

Client Name

Client Date of Birth

Client Address

Client Phone Number

Case Manager/Paralegal

Attorney Name

Attorney's Office Phone Number

Procedure(s) Needed: Please indicate below
Telehealth Initial ConsultationComprehesive In-Home Diagnostic Testing (ALL)Cognitive ERP/EEG & Balance Test ONLYVestibular & Oculomotor Test ONLYPsychiatric EvaluationVideo Ambulatory EEG (24 Hr)

Please indicate if Treatment is needed:
6 Week - NeuroCognitive & Vestibular Treatment Protocol12 Week - NeuroCognitive & Vestibular Treatment Protocol6 Month - NeuroCognitive & Vestibular Treatment Protocol

Upload File

Please include any relevant clinical notes or reports