Evaluation Enrollment Form

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Please use our updated form:To enroll in a psychological evaluation, make sure to complete our newest intake form here: 👉 https://form.jotform.com/250077134118046 (Older links are now outdated and won’t reach the correct team.)
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Who will be receiving services?* This field is required.We offer psychological testing for children (5+), teens, and adults.
My Child
Me
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Has any member of your immediate household ever received care at Mala?* This field is required.
Yes, Psychotherapy
Yes, Medication Managment
Yes, Occupational Therapy
No
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Your Name* This field is required.If you are a parent or guardian, please put your name here.
First Name
Last Name
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Phone Number* This field is required.
Please enter a valid phone number.
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Email* This field is required.
example@example.com
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Client's Name* This field is required.If under 18 years of age.
First Name
Last Name
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Client Pronouns
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Client's Date of Birth* This field is required.This is the date of birth of the person you are seeking care for.
Date
Year
Month
Day
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Relationship to Client* This field is required.Ex: parent, self
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Contact #2 Name* This field is required.*If this is a divorced or separated household this MUST be the second parent.
First Name
Last Name
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Contact #2 Email* This field is required.*If this is a divorced or separated household this MUST be the second parent.
example@example.com
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Contact #2 Phone Number* This field is required.*If this is a divorced or separated household this MUST be the second parent.
Please enter a valid phone number.
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What is Contact #2's relation to you or your child?* This field is required.
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Is your child in a divorced or separated household? * This field is required.
YESNO
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Who is your insurance carrier?* This field is required.We are in-network providers with Blue Cross Blue Shield (BCBS) for psychological evaluations. We cannot accept Blue-Care Network (BCN) or Aetna. You can review our private pay fees on our website.
Blue Cross Blue Shield (BCBS)
Private Pay - Out of Pocket
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Upload photos of insurance card (front and back), if applicableFront & Back
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Primary Insured Date of Birth
Date
Year
Month
Day
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Upload photos of driver's licenseFront & back
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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What testing services are you seeking?* This field is required.Please select all that apply.
Adult ADHD Assessment (Virtual Only)
ADHD
Anxiety Disorders (i.e., OCS or GAD)
OCD
Depressive Disorders (i.e., MDD)
Specific Learning Disorders (ex: Dyslexia)
Executive Functioning (memory, attention, organization)
Cognitive Strengths and Difficulties (IQ)
Academic skills and learning
Developmental Delays
Personality Functioning
Social, Emotional, and Behavioral Concerns
Trauma
PTSD
ASD
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Please summarize your goals for psychological testing.* This field is required.
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Has the client received any prior psychological testing?* This field is required.
YESNO
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If yes, when was the testing done?
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If you have had previous testing, upload that report here:
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Has the client ever been previously diagnosed with anything? If so, who made the diagnoses?
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Are you seeking this evaluation as a result of a court hearing or custody agreement?* This field is required.
YESNO
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Are you seeking this evaluation to obtain disability, social security, or job readiness?* This field is required.
YESNO
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Are you seeking this evaluation to assess neurological functioning, including memory decline?* This field is required.Ex: Dementia, Traumatic Brain Injury
YESNO
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Would you like to be added to our newsletter? * This field is required.
YESNO
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How did you hear about Mala Child & Family Institute?
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