Appointment Request Form

Appointment Request Form

You may also email us at Referrals@AtlantaPsychological.com or call 770-457-5577 with any questions.
Date*

MonthDayYear
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.
Primary Reasons for Seeking Evaluation/Consultation:

ADHD / Attention & Executive FunctioningAutism Spectrum / Social-Communication ConcernsLearning Disorder (Reading/Dyslexia, Math, Writing)Academic Accommodations (IEP, 504 Plan, SAT/ACT/LSAT)Giftedness / IQ TestingDiagnostic Clarification (Complex Mood, Anxiety, or Personality)Treatment Resistant / Lack of Progress in TherapyRule-Out Bipolar vs. Trauma/PTSDBehavioral Dysregulation (Oppositional, Impulse Control)Psychosexual Evaluation / Risk AssessmentCourt-Ordered Mental Health EvaluationDFCS / CPS ReferralOther
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Client or Parent/Legal Guardian E-mail*
Parent/Legal Guardian's Name (if applicable)

First NameLast Name
Can the appointment be via phone or video conferencing if possible?*
Name of person to contact for scheduling (if not the client or a legal guardian).

First NameLast Name
Best phone number for scheduling the appointment:*

Area CodePhone Number
What is the above person's relationship to the client (for scheduling purposes)?
Name of person completing this form, if not the client or a legal guardian.

First NameLast Name
If you are not the client, what is your relationship to the client?
How did you find us?
Please specify name of referring person/agency and profession, if known.
(For example, Dr. Smith - ABC Surgery Center)
I understand that the providers at Atlanta Psychological Services (Dr. George, Dr. Gothard, and Dr. Hay) are out-of-network (self-pay) providers and do not bill insurance directly. I acknowledge that initial consultations are $200, standard evaluations typically start at $1,500, and specialized custody/court-related work is billed at $275/hour due to the higher level of expertise required.
Acknowledgment:*

I have read and understand the financial policies and fee structure above.
By signing and submitting this form, you give the clinicians and employees of Atlanta Psychological Services permission to call you for scheduling. 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.
Client Signature / Legal Guardian's Signature*

Clear
Should be Empty: