ADHD 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 Attention-Deficit Hyperactivity Disorder and accompanying accommodations and/or treatment recommendations. Please note, not everyone needs a full assessment and our Assessment Coordinator 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 three 60 minute sessions.

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 Assessment Coordinator, 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, a CCW clinician will confirm this appointment. After the screening video call, if it is determined that a CCW assessment would be appropriate, we will schedule you for your first assessment appointment with Julie Hazel and send you the necessary paperwork to complete before your first appointment.

Appointment #1- 60 minutes in person

Julie 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 Julie will gather any additional information that she may need to finish the evaluation.

Appointment #3- 60 minutes in person or virtual

You and Julie will review your completed assessment report, including recommendations and/or accommodations, and you will receive a copy of the final evaluation.

Financial Commitment

CCW does not bill insurance for ADHD assessments. Many insurance plans do not cover the service and we have determined that it is more efficient and cost effective for our clients to charge a flat fee for services.

The total cost for the evaluation and final report is $800. Once you complete your initial screening call, we will collect a $100 nonrefundable deposit to secure your first 60 minute assessment appointment. Please note, the fees will need to be paid in full in order to release your final report. The payment schedule is as follows:

$100 nonrefundable deposit is charged to secure your first appointment

$300 due at first appointment

$400 due at final appointment to release report

Do you have active Medicaid?*

YesNo

If you have active Medicaid and are a current CCW client (you have been seen within the last 30 days), 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

I understand and acknowledge all requirements and commitments related to undergoing an ADHD 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

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:

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.