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Which office is your appointment in?*
- Toms River
- Freehold
Is this appointment related to any legal matters, custody or guardianship arrangements?*
- Yes
- No
If yes, explain:*
PATIENT REGISTRATION
Please complete all information
Patient Name*
First Last
Address*
Street Address City State ZIP Code
Email*
Best Phone # to Reach You*
Date of Birth*
Month
Day
Year
Sex*
- Male
- Female
Social Security #
Marital Status*
- Married
- Single
- Divorced
- Widowed
- Engaged
Full Name of Referring or Primary Care Physician
First Last
Dr.'s Phone #
Dr.'s Address
Street Address City State ZIP Code
Emergency Contact Person
First Last
Emergency Contact Phone #
Employer
School
INSURANCE INFORMATION
If not known, please enter N/A
Insurance Name*
Phone*
Address*
Street Address City State ZIP Code
ID #*
Group #*
Insured Full Name*
Insured Date of Birth*
Month
Day
Year
Insured Relationship to Patient*
Insured Employer*
INSURANCE CARD PHOTO UPLOAD
Please upload a picture of the front and back of your insurance card
Front of Card*
Accepted file types: jpg, png, pdf, Max. file size: 5 GB.
Back of Card*
Accepted file types: jpg, png, pdf, Max. file size: 5 GB.
SECONDARY INSURANCE (Medicare patients only)
Insurance Name
Phone
Address
Street Address City State ZIP Code
ID #
MOTOR VEHICLE INSURANCE (Motor Vehicle patients only)
Motor Vehicle Insurance Name
Address
Street Address City State ZIP Code
Adjuster Name
Phone
Claim #
RELEASE FOR PROFESSIONAL INFORMATION
I hereby authorize Pathways Neuropsychology Associates to obtain or release protected information pertaining to my treatment. This information should only be released to the following:
PCP/Physicians
Attorney
Other
If patient is a minor, parent or guardian are required to sign this release. If minor is 14 years or older, their signature is also required.
Signature*
Relationship
APPOINTMENT CANCELLATION POLICY
We reserve the right to charge a reasonable and customary fee, $50.00 for missed appointments or services scheduled for you if you...
1. Fail to call 24 hours in advance to cancel or reschedule.
2. Fail to attend the appointment without giving 24 hours notice.
3. Arrive too late for the doctor to see you at your scheduled time.

This is to confirm that I have been made aware of the above policy.
Signature*
Date*
Month
Day
Year

CLIENT HISTORY
Please complete to the best of your knowledge. Try being as exact as possible in your answers.
MEDICAL/HEALTH INFORMATION
How were you referred to this office? (name of referring physician or organization)
Reason for referral
Please list your current medications*
Has client ever had:
- Head injury
- Stroke
- Other brain injury
- Concussion
- Loss of consciousness or coma
Date(s) this occurred / Length of unconciousness or coma
Has client had surgery?*
- Yes
- No
If so, please provide details
PAST MEDICAL & PSYCHOLOGICAL TESTS
Has client ever had any of the following tests:
- Neurologic exam
- MRI
- CAT (CT) Scan
- EEG
- Psychological Tests/Evaluation
Date(s) of test
Details?
PAST MEDICAL & PSYCHOLOGICAL HISTORY
Has client ever (prior to the current incident) had:
- Diabetes
- Heart disease
- High blood pressure
- Seizures
- Thyroid problems
- Asthma
- Learning disabilities
- Drug or alcohol abuse
- Psychological/Psychiatric problems
- Neurological disease
- Surgery
- Toxic exposures
- Parkinson's Disease
- Fibromyalgia
- Hydrocephalus
- Dementia
- Sleep apnea
- Multiple sclerosis
- Chronic Obstructive Pulmonary Disease (COPD)
Other medical disease?
If so, when? Details?
ALCOHOL/TOBACCO USAGE
Please select the one that applies to the client
- Never or rarely drinks alcohol
- Drinks socially only
- Drinks nearly every day
- Has been treated for alcoholism
- Does not smoke
Smokes how many packs of cigarettes per day?
FAMILY HISTORY
MOTHER:
Age
Deceased?
If so, when?
Cause
FATHER:
Age
Deceased?
If so, when?
Cause
Any brothers and/or sisters?
- Yes
- No
Names & ages
Any children?
- Yes
- No
Names & ages
Do any family members have any of the following: (if so, please specify who)
Psychiatric or psychological problems?
ADHD?
Learning disabilities?
Alcoholism/Substance Abuse?
Alzheimer's Disease or Dementia?
Other Neurological problems?
MARITAL HISTORY
Is client currently*
- Married
- Single
- Divorced
- Widowed
- Engaged
If married, how long?
LIVING ARRANGEMENTS
List everyone living in the home (Name, age & relationship)
SOCIAL HISTORY
EDUCATION:
Highest grade or degree completed*
If you attended college, which one?
Learning disabilities?*
WORK:
Is client working now?*
If not, when did you stop?
Present occupation?
How long at present work?
Other Comments or Relevant Information

SYMPTOM CHECKLIST
Check all that apply
PHYSICAL*
- Headaches
- Backaches
- Sexual Problems
- Significant weight change
- Numbness/weakness on either side of body
- Heart pounding/racing
- Poor vision
- Sensitivity to light
- Sensitivity to noise
- Hearing impairment
- Tinnitus (ringing in the ears)
- Decrease/increase in appetite
- Change in taste
- Change in smell
- Loss of balance
- Poor coordination
- Nausea
- Sweating hands/feet
- Teeth grinding/clenching
- Pain
- None
Describe the location of the pain
COGNITIVE*
- Forgetfulness
- Poor concentration
- Slowed thinking
- Difficulty managing daily activities
- Difficulty making decisions
- Changes in judgement
- Difficulty understanding what others say
- Language/speech difficulty
- None
Explain language difficulty
EMOTIONAL*
- Changes in personality
- Feelings of depression
- Feelings of irritability
- Frequent racing thoughts
- Anxiety/fear/panic
- Feelings of unreality
- Nervousness/shakiness
- Decreased energy
- Fear of riding/driving in an automobile
- Flashbacks
- Thoughts of hurting yourself
- Thoughts of hurting others
- None
SLEEP*
- Trouble falling asleep
- Nightmares
- Sleeping more than usual
- Sleeping less than usual
- None
SOCIAL*
- Marital discord
- Problems with family/friends
- Problems in work performance
- Trouble participating in sports
- Academic difficulties
- Trouble participating in social settings
- None
PATIENT HEALTH
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things*
- Not at all
- Several days
- More than half the days
- Nearly every day
Feeling down, depressed, or hopeless*
- Not at all
- Several days
- More than half the days
- Nearly every day
Trouble falling or staying asleep, or sleeping too much*
- Not at all
- Several days
- More than half the days
- Nearly every day
Feeling tired or having little energy*
- Not at all
- Several days
- More than half the days
- Nearly every day
Poor appetite or overeating*
- Not at all
- Several days
- More than half the days
- Nearly every day
Feeling bad about yourself - or that you are a failure or have let yourself or your family down*
- Not at all
- Several days
- More than half the days
- Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television*
- Not at all
- Several days
- More than half the days
- Nearly every day
Moving or speaking so slowly that other people could have noticed. Or the opposite - being so figety or restless that you have been moving around a lot more than usual*
- Not at all
- Several days
- More than half the days
- Nearly every day
Thoughts that you would be better off dead, or of hurting yourself*
- Not at all
- Several days
- More than half the days
- Nearly every day
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
- Not difficult at all
- Somewhat difficult
- Very difficult
- Extremely difficult

CONSENT FOR PURPOSES OF TREATMENT & HEALTHCARE OPERATIONS
I consent to the use or disclosure of my protected health information by Pathways Neuropsychology Associates for the purpose of diagnosing or providing treatment to me and in obtaining payment for my health care bills. I understand that diagnosis or treatment of me by Pathways Neuropsychology Associates may be conditioned upon my consent and evidenced by my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. Pathways Neuropsychology Associates is not required to agree to a restriction that I request. However, if Pathways Neuropsychology Associates agrees to a retraction that I request, the restriction is binding on Pathways Neuropsychology Associates. I have the right to revoke this consent, in writing at any time, except to the extent that Pathways Neuropsychology Associates has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by Pathways Neuropsychology Associates, another health care provider, a health plan, my employer, or a health care clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have the right to review Pathways Neuropsychology Associates Notice of Privacy Practices prior to signing this document and this has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of bills, or in the professional health care operations of Pathways Neuropsychology Associates. this Notice also describes my rights and Pathways Neuropsychology Associates duties with my protected health information.

Pathways Neuropsychology Associates reserves the right to change the Privacy Practices that are described. I may obtain a revised copy by calling the office, and I have the right to revoke this consent at any time.

Our office will make every attempt to collect payment from your insurance company. Please remember that payment of your bills is ultimately your responsibility. Your deductible and co-payment amounts are determined by the insurance coverage you and your employer selected. You are required to pay these deductibles and co-payments at the time of service. If you are in dispute of these amounts, it is your responsibility to address the problem with your insurance company. All individual providers are billed under Tax ID #81-3236538. It is your responsibility to use this information to confirm that your provider is “in-network.” A “covered service” does not necessarily mean that it will be a paid service. As a result, you may be financially responsible for all or part of the services provided by our office.

I have read the information listed above and understand that I am financially responsible for all services not paid by my insurance company.
Patient Name*
First Last
Date*
Month
Day
Year
Signature*

INFORMED CONSENT CHECKLIST FOR TELEPSYCHOLOGICAL SERVICES
Prior to starting video-conferencing services, we discussed and agreed to the following:

• There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.

• Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).

• We agree to use the video-conferencing platform selected for our virtual sessions, and the psychologist will explain how to use it.

• You need to use a webcam or smartphone during the session.

• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.

• It is important to use a secure internet connection rather than public/free Wi-Fi.

• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the psychologist in advance by phone or email.

• We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.

• We need a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation.

• If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.

• You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.

• As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.
Patient Name
First Last
Date
Month
Day
Year
Signature of Patient/Patient's Legal Representative
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Health & Rehabilitation Services
Jay B. Gordon, Ph.D.
NJ Licensed Psychologist #37590

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Office Locations

Main Office:
phone: (732) 930-2242
fax: (732) 569-6819
334 Commons Way
Toms River, NJ 08755

Satellite Offices:
55 Schanck Road, Suite A-6
Freehold, NJ 07728

1301 Route 72 West, Suite 250
Manahawkin, NJ 08050

235 East Jimmie Leeds Road
Galloway, NJ 08205

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We are pleased to announce our new Toms River location at 334 Commons Way in Toms River, NJ as of 11/29/24 Learn more