BASIC INFORMATION
Name
*
First Name
Last Name
Parent, guardian, caregiver name (or leave blank if adult); church/pastor (if for clergy assessment); foster/adoption agency (if for a pre-adoption parent evaluation)
First Name
Last Name
Phone Number
*
If appointment is for a minor, please provide parent or guardian phone number.
Email
*
NOTE: Only enter 1 email address. If appointment is for a minor, please provide parent or guardian email.
Client Age
*
Client Date of Birth
*
-
Month
-
Day
Year
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County of Residence
*
Please Select
Orange County
Los Angeles County
Other
If "other", what county do you live in?
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Reason for seeking psychological testing:
*
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How did you hear about us?
Please Select
CIFT Therapist
Therapist Outside of CIFT
Psychiatrist or psychiatric nurse practitioner
Pediatrician or physician
School
CIFT Website
Self-referred or referred by parent
Church
Friend/relative
Psychology Today website
Other
If you were referred by a therapist, psychiatrist, pediatrician/physician, school or church, please share which one:
If other, please explain
SUBMIT REQUEST
Should be Empty: