FAA Evaluation Request

To initiate an appointment for an FAA-related psychological or neuropsychological evaluation, please complete the form below.

Evaluation appointments are only available on Mondays and Thursdays.

Full legal name*

I am completing this form for myself.*

Yes

No

If no, please provide name and relationship to the patient of the person completing this form.

Primary phone number*

Is it okay for our office to leave a voicemail including appointment details at the provided number?*

Yes

No

Email address*

Mailing address

Preferred contact method*

Phone

Email

Reason for evaluation as described by your AME or the FAA*

Have you received a letter from the FAA (AMCD) requesting this evalaution?*

Yes

No

Unsure

AME name

FAA submission deadline, if stated:

I acknowledge that I have reviewed the FAA evaluation information provided by email, including the requirements for scheduling and completing the evaluation, applicable timelines, required documentation, and verification of the appropriate evaluation protocol.*

I acknowledge.

ADDRESS

6737 W. Washington St. Suite 3355
West Allis, WI 53214

CONTACT

info@mathyneuropsych.com
262.671.2437