Request Appointment

Would you or someone you know benefit from a neuropsychological evaluation? There are three ways to schedule an initial consultation:

  1. The easiest way is to have your doctor fax a referral form to be referred to Coastal Neuropsychology Services at (844) 965-9874.
  2. Complete the online form below. (Please provide your insurance information, including your ID number).
  3. You also can call Dr. Chasman directly at (843) 990-6293.

We strive to provide excellent service and will endeavor to contact you as soon as possible, usually within one business day. Please note that submitting this form does not guarantee an appointment. If we cannot accommodate your needs, we will provide you with additional resources and referrals.

Online Form:

Email/Internet Privacy Notice:
While unlikely, I accept that a breach of my privacy could occur when sending this information over the internet and/or when communicating by email. I am willing to accept that risk. I also understand that I have the option of printing this form and faxing it in or calling the office. For information on how we protect your privacy, please click here to view the Coastal Neuropsychology privacy policy

Alternatively, you may Print Intake Form & fax to (844) 965-9874.

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