Forms

New Patients
may download and complete the following six forms to bring to the initial appointment. If preferable, patients may also come 30 minutes prior to the initial session to complete forms in the waiting area. The doctor will review all the paperwork during the first meeting, and will address any questions at that time. If patients are seeking insurance authorization for psychological services, it would be helpful to contact them in advance by calling the number on the back of the insurance card to ensure benefits coverage. You will also need to bring your insurance card to the first appointment.

1. Face Sheet (Demographics/Insurance Information)
2. Treatment Agreement (Services Contract)
     a. QEEG/Neurotherapy
     b. Psychotherapy, Testing, Groups, Classes
3. Authorization (Release Form)
4. Privacy Policy
5. Request for Confidential Handling of Private Health Information
6. History Questionnaire
     a. Adult
     b. Child/Adolescent
     c. Chronic Pain


Case Studies - read how neurotherapy helped change lives
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1/6/08 - Dr. Kirk Little provides insight into kids drawn to “thrill seeking” behavior in Enquirer article.
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6900 Houston Rd
Building 500 Suite 11
Florence, KY 41042

Phone: 859-525-4911
Fax: 859-525-6446

10979 Reed Hartman Highway
Suite 135F
Cincinnati, OH 45242