New Patient Forms

For your convenience you can find most of the clinic's forms on this page. Please complete the forms that pertain to the type of service you are seeking to make your first appointment more efficient. If you have any questions about which forms you need to complete, do not hesitate to call us.
The .pdf forms are fillable; however, your answers cannot be saved. Please make sure to print the completed forms.

HIPPA form

 

Referral Form

 

Consent to treatment​

Caregiver's Authorization Affidavit

 

Demographics Form

Child Intake Questionnaire 

Adult Intake Questionnaire 

 

Authorization to Release Records

 

Financial Policy

Note  ​

For the patients seeking an evaluation:

​* It is very important that the patient is well rested and had a nutritious meal before arriving for his/her assessment appointment.

* Bring copies of any prior psychological, psychoeducational, neuropsychological testing reports and IEP paperwork to your first appointment.

Office Location
15335 Morrison Street, Ste. 205
Sherman Oaks, CA 91403
Office Hours
Monday - Saturday
By appointment only
​E-Mail: ​dr.zaytsev@gmail.com 
Tel:  323-682-8225​
Fax: 323-396-9987

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