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Mala Child & Family Institute Evaluation Waitlist

Mala Child & Family Institute Evaluation Waitlist

Please complete and submit this form to be added to our evaluation waitlist. Our evaluation services are currently on a waitlist. We are scheduling a month out for virtual only adult (18+) ADHD evaluations. We only accept BCBS for our evaluation services at this time. In-person evaluations are available at our Ann Arbor and Farmington Hills locations. Completing this form will automatically add you to our evaluation waitlist. We will contact you once an appointment is available. 
30Questions
  • 1
    We offer psychological testing for children (5+), teens, and adults.
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  • 2
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  • 3
    If you are a parent or guardian, please put your name here.
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  • 6
    Please Select
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    • Philippines
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    • 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
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    • San Marino
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    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
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    • Suriname
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    • Taiwan
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    • Trinidad and Tobago
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    • Western Sahara
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    • Other
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  • 7
    If under 18 years of age.
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  • 8
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  • 9
    This is the date of birth of the person you are seeking care for.
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    Pick a Date
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  • 10
    Ex: parent, self
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  • 11
    *If this is a divorced or separated household this MUST be the second parent.
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  • 12
    *If this is a divorced or separated household this MUST be the second parent.
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  • 13
    *If this is a divorced or separated household this MUST be the second parent.
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  • 14
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  • 15
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  • 16
    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.
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  • 17
    Front & Back
    Drag and drop files here
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    Max. file size: 10.6MB
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  • 18
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    Pick a Date
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  • 19
    Front & back
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    Max. file size: 10.6MB
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  • 20
    Please select all that apply.
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  • 21
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    Drag and drop files here
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  • 26
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  • 27
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  • 28
    Ex: Dementia, Traumatic Brain Injury
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  • 29
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  • 30
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