Appointment Request Form

Appointment Request Form
For more information, visit us online at www.AtlantaPsychological.com.

For questions or problems completing this form, please give us a call and leave a voicemail at 770-457-5577. You may also email us at Referrals@AtantaPsychological.com with any questions.
Date *

Month Day Year
Date
Which clinician are you requesting to see? (if known) *
What appointment needs do you have? *
If you need to schedule or reschedule an appointment that is to take place in the next 24 hours, or the next business day, please call our office. For emergencies, please call 911.
What type of evaluation is needed?
(i.e., psychological, psychoeducational, neuropsychological, etc.)
What type of court-related evaluation is needed?
Client Name *

First Name Last Name
Client Date of Birth *

Month Day Year
Date
Check all that apply for the patient:

Emotional concerns (i.e., anxiety, depression, anger) Behavioral concerns Educational or learning problems Developmental delays (i.e., cognitive, speech, motor, language, possible Autism) Substance use problems Legal problems Attention problems/hyperactivity (ADHD concern) Parenting difficulties Family conflict Need to determine what kind of treatment is needed for mental health issues. Need to determine if there is a mental health diagnosis.
Are there any other special considerations or reasons for the requested appointment?
Client Phone # (or best number for contacting you about an appointment) *

Area Code Phone Number
Are you will to having the appointment via phone or video conferencing if possible? *
Client or Parent/Legal Guardian E-mail *
Parent/Legal Guardian's Name (if applicable)

First Name Last Name
Name of person completing this form, if not the client or a legal guardian.

First Name Last Name
If you are not the client, what is your relationship to the client?
Client Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Source of Payment *
Primary Insurance
(1) Client's Insurance Provider
(1) Insurance Phone Number (on back of the ID card)

Area Code Phone Number
(1) Insurance Member ID
(1) Click below to upload a photo of the FRONT of your insurance card (not required):
(1) Click below to upload a photo of the BACK of your insurance card (not required):
Secondary Insurance (if applicable)
(2) Does the client have secondary insurance?
(2) Secondary Insurance Provider
(2) Insurance Member ID
(2) Insurance Phone Number (on back of the ID card)

Area Code Phone Number
(2) Click below to upload a photo of the FRONT of your insurance card (not required):
(2) Click below to upload a photo of the BACK of your insurance card (not required):
What days work best for an appointment? *

Monday Tuesday Wednesday Thursday Friday
What time works best? *

Morning Afternoon
Preferred Contact Method *

Client or guardian phone number given above. Client or guardian email address given above.
By signing and submitting this form, you give the clinicians and employees of Atlanta Psychological Services permission to contact you based on your preferred contact method. You are also certifying that all information provided in this form is true and correct to the best of your knowledge.

Contact us via phone at 770-457-5577 with any questions or problems about this form.
For identification verification, please upload a photo of your picture ID
Client Signature / Legal Guardian's Signature *

Clear
Should be Empty: