Identity Aligned ADHD and Autism Assessment Inquiry Form

Before completing this form to move forward with scheduling, please read all the information below to ensure you understand the time and financial commitment involved for the assessment process.

Clintonville Counseling & Wellness provides comprehensive assessments for people who may need formal documentation of an Autism and/or Attention-Deficit Hyperactivity Disorder and accompanying accommodations and/or treatment recommendations. Please note, not everyone needs a full assessment and our Programming & Culture Director, Julie Hazel LPCC-S, will help you determine if there are more accessible, less time consuming, and more cost effective options for getting your needs met. We are currently only providing assessment services for persons 18 and older at this time.

Here is what to expect from the assessment process:

Time Commitment

Our assessment process consists of one 10-15 minute video screening followed by two 60 minute sessions and one 30 minute follow up session.

Screening Video Call- 10 to 15 minutes

The first step in this process is a 10-15 minute complimentary screening to determine if our program is the best fit for your needs. Once you complete this request form, our Programming & Culture Director, Julie Hazel (they/she), will email you a link to the online scheduling portal, Simple Practice, where you will schedule your screening video call. Once you select the appointment that works best, Julie will confirm this appointment. After the screening video call, if it is determined that a CCW assessment would be appropriate, Julie will assist in scheduling you for your first assessment appointment with a CCW clinician and send you the necessary paperwork to complete before your first appointment.

Appointment #1- 60 minutes in person

A clinican will complete an interview to obtain information about your history, symptoms, and current functioning.

Appointment #2- 60 minutes in person

You will complete several assessment measures (written, on the computer, and verbal) and a CCW clinician will gather any additional information that they may need to finish the evaluation.

Appointment #3- 30 minutes virtual

You and your clinician will review your completed assessment report, including recommendations and/or accommodations.

What assessment(s) are you interested in?*

ADHD evaluation onlyAutism evaluation onlyBoth an ADHD and Autism evaluation

Do you have active Medicaid?*

YesNo

Financial Commitment:

CCW does not bill insurance for assessments. Many insurance plans do not cover this service, so we use a flat fee to make the process straightforward and cost-effective.

If you currently have active Medicaid, you will receive a reduction in cost and the total cost is reduced to $460. The payment schedule is as follows:

$100 nonrefundable deposit is charged to secure your first appointment

$120 due at first appointment

$120 due at second appointment

$120 due at final appointment to release report

Financial Commitment:

CCW does not bill insurance for assessments. Many insurance plans do not cover this service, so we use a flat fee to make the process straightforward and cost-effective.

The total cost for the evaluation and final report is $800. A $100 non-refundable deposit is collected after your initial screening call to secure your first 60-minute assessment. All fees must be paid in full before the final report is released.

Flexible Payment Options:
We offer flexible self-payment plans in consultation with the Programming and Culture Director. For example:

Deposit: $100

First appointment: $250

Second appointment: $250

Third appointment: $200

Other arrangements can be discussed to fit your needs and support a smooth evaluation process.

Financial Commitment:

CCW does not bill insurance for assessments. Many insurance plans do not cover this service, so we use a flat fee to make the process straightforward and cost-effective.

If you currently have active Medicaid, you will receive a reduction in cost and the total cost is reduced to $550. The payment schedule is as follows:

$100 nonrefundable deposit is charged to secure your first appointment

$150 due at first appointment

$150 due at second appointment

$150 due at final appointment to release report

Financial Commitment:

CCW does not bill insurance for assessments. Many insurance plans do not cover this service, so we use a flat fee to make the process straightforward and cost-effective.

The total cost for the evaluation and final report is $950. A $150 non-refundable deposit is collected after your initial screening call to secure your first 60-minute assessment. All fees must be paid in full before the final report is released.

Flexible Payment Options:
We offer flexible self-payment plans in consultation with the Programming and Culture Director. For example:

Deposit: $150

First appointment: $250

Second appointment: $250

Third appointment: $300

Other arrangements can be discussed to fit your needs and support a smooth evaluation process.

I understand and acknowledge all requirements and commitments related to undergoing an ADHD and/ or Autism assessment.*

YesNo

If you would like to move forward with scheduling a screening video call, please complete the following information and an email will immediately be sent to you with instructions on how to select a time and date for your appointment.

Your Name*

First NameLast Name

Date of Birth

Date

Medicaid ID #:

Are you currently a client at Clintonville Counseling and Wellness?*

YesNo

Name of CCW Therapist*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Days and times available for a screening phone call

First choice day:

First choice time of day (select all that work):

MorningAfternoonEvening

Second choice day:

Second choice time of day (select all that work):

MorningAfternoonEvening

Reason for requesting assessment:*

Any additional information you want us to know:

Please upload the Front of your Medicaid Insurance Card

Please upload the Back of your Medicaid Insurance Card

By hitting the "Submit" button below, you acknowledge that instructions on how to schedule your screening video call will be provided to you via email. You should receive this email within 30 minutes of submitting form. Please be sure to check your Spam Folder to avoid missing this email.