New Customer Intake Form

What services are you currently interested in?*

ADHD Testing - ONLINEADHD Testing - IN OFFICE
Were you SEEN at and REFERRED by a provider at one our Affiliate offices for ADHD testing?*

NoYes - was seen at and referred by Renewed Mental Health GroupYes -was seen at and referred by Orange Coast PsychiatryOther

Did you receive a Referral and/or an Order* from a Qualified Mental Health or Medical Professional to get ADHD Testing?*

YesNo
A written referral and/or order from a qualified, licensed mental health or healthcare professional is REQUIRED for ADHD testing services.

A qualified California licensed mental health or healthcare professional, such as your Primary Care Provider (PCP), Physician, Pediatrician, Primary Care Doctor, Mental Health Provider (including psychiatrists, psychologists, psychiatric-mental health nurse practitioners, physician assistants, and occasionally licensed clinical social workers or licensed marriage and family therapists), or another licensed mental health professional, can assist you with a referral/order to get ADHD Testing Services.

Please note: If you were referred by any of the mental health clinics listed below, you DO NOT need to provide proof of a written referral or order. Our team will contact them directly to obtain one, as we are a preferred vendor. You are still required to give us authorization to communicate with them on your behalf, which you will authorize by completing this form
- Renewed Mental Health Group
- Orange Coast Psychiatry
Do you have a copy of your Referral/Order for ADHD testing that you can upload?*

YesNo
Please upload a copy of your Referral/Order that you received for ADHD Testing

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Please note, you must provide proof of the Written Referral and/or Order prior to taking test. You may fax or email the referral/order directly to us, or you may have your qualified provider fax or email it us.

You may submit your referral/order at a later time, as long as its before you take your test.
If you DID NOT receive an order or referral for ADHD Testing, please read:

To facilitate the referral process for ADHD testing services at Simple ADHD Testing, we offer two convenient options:

Option 1: Use our referral form, which is available on our website. This form has been specifically designed to capture all necessary information in a structured format for your convenience.

Option 2: Submit a written order directly.

If you choose this option, please ensure that the written order includes the following essential information:

- Full name and contact details of the referring professional.
- Your full name and date of birth.
- A clear statement indicating the need for ADHD testing.
- Any relevant clinical observations or initial symptom evaluations.
- The date of the referral and the provider's signature.

These options are designed to ensure that all necessary details are provided to confirm the appropriateness of ADHD testing for your specific situation and to verify that your initial symptoms have been professionally assessed.
- Referring Provider: Licensed Mental Health or Healthcare Professional

Please enter the information of your referring/ordering qualified licensed professional below.

Please enter the correct information to allow us to send your results to them directly or contact them if we need further information.
- Provider Referral: Licensed Mental Health or Healthcare Professional

Please enter the information of the qualified licensed professional that you will be requesting a referral/order from.

Please enter the correct information to allow us to send your results to them directly or contact them if we need further information
Referring Provider: Full Name*

First NameLast Name
Referring Provider: Professional Title*
Referring Clinic Name:
Referring Provider: Office Phone Number*
Referring Provider: Office Fax Number*
Referring Provider: E-mail*
example@example.com
Referring Provider: Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
- Referring Provider: Licensed Mental Health or Healthcare Professional

Please enter the information of your referring/ordering qualified licensed professional below.

Please enter the correct information to allow us to send your results to them directly or contact them if we need further information.
Referring Provider Full Name*
Referring Clinic and Address*

Customer Identification Verification

We must verify the Customer/Test Taker's identity and/or their Legal Guardians identity.

Without these forms of ID, we will not be able to provide testing services

*If the customer/test taker is a minor, please upload a copy of one of their Parent/Legal guardian's Government Issued ID.
Please upload a copy of one of the following for the Customer/Test Taker: Passport, Driver's License, or Government-issued State ID (one is required)*

*If the customer/test taker is a minor, please upload a copy of one of their Parent/Legal guardian's Government Issued ID.
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Release of Information

I, the customer/test taker or legal representative of the customer/test taker, hereby authorize the release of any relevant information pertaining to my ADHD (Attention Deficit-Hyperactivity Disorder) testing and other pertinent documents/documentation that may aid my provider conducted by Simple ADHD Testing LLC. I hereby authorize Simple ADHD Testing LLC, its affiliates, its staff, contractors, and providers to REQUEST AND DISCLOSE INFORMATION TO AND FROM the client or Organization/Clinic or referring Provider above and have a bilateral exchange of information. This includes, but is not limited to, test results, questionnaires, assessments, and related medical records. I understand that this information may be shared with authorized healthcare professionals and entities involved in my care, as deemed necessary for treatment purposes, including the Referring professional listed in this document. I acknowledge that this authorization is voluntary and can be revoked at any time, except to the extent that action has been taken in reliance on it. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. I have read and understood the terms of this Release of Information statement, and I consent to the sharing of my ADHD testing and other information as described above. As the individual undergoing the test or as the parent/legal guardian/legal representative of the individual undergoing the test, I further acknowledge and hereby authorize Simple ADHD Testing LLC, its affiliate clinics, and its other affiliates, to engage in a bilateral exchange of information contained within my medical records under the specified conditions. I grant permission for Simple ADHD Testing LLC, its affiliate clinics, and its affiliates, to both disclose and receive information pertaining to my diagnosis and treatment. This exchange is aimed at facilitating the transmission of ADHD testing results to my primary care provider, mental health professional, or other healthcare providers. Additionally, it serves to enhance the understanding of my medical history, diagnosis, and treatment; to ensure coordinated care with other healthcare professionals involved in my treatment; and to allow for discussions about my care with friends or family members who provide support. I explicitly authorize Simple ADHD Testing LLC to administer testing, and to release and receive information and medical records to and from all involved providers, healthcare professionals, and physicians. This includes the authority to submit claims to my insurance company on my behalf, to appeal any denied claims with my insurance company, and to release or obtain information and records related to my or my dependent's illness, injury, condition, and treatment to and from my attorney or employer as necessary. I understand that this consent includes the assignment of all payments for medical services rendered to me or my dependents directly to the provider. I acknowledge that this comprehensive authorization is crucial for the seamless management of my ADHD testing process, ensuring that all necessary parties are informed and engaged in my care, and that my insurance and legal rights are appropriately managed. This consent is given freely and with a full understanding of its implications in the context of my ADHD testing and treatment.
Informed Consent for ADHD Testing Services Document
By signing below, I as the individual undergoing testing or as the parent/legal guardian/legal representative of the tester, hereby acknowledge that I have read the document titled 'Informed Consent for ADHD Testing Services' and the 'Release of Information Statement' in its entirety. By signing/acknowledging this statement, I affirm that I understand and agree to the contents of the aforementioned document and statement. I acknowledge that my acceptance of the terms and conditions outlined within the document is legally binding. I understand that failure to abide by the terms set forth may result in legal consequences. Furthermore, I confirm that I have had the opportunity to seek legal advice or clarification on any aspects of the document prior to acknowledging it. Lastly, i attest that i have received or will have received a referral and/or medical order to get ADHD testing from a qualified mental health and/or medical professional licensed in the state of California. This acknowledgment is made voluntarily and without any coercion or duress.
Customer or Parent/Legal Guardian/Legal Representative Signature*

Clear
Customer or Parent/Legal Guardian/Legal Representative Full Name*

First NameLast Name
Should be Empty:

ADHD Testing Intake Form - New Customer

Customer/Test Taker Details

For Minor Test Takers Only (Test Taker is below 18 years old)