AuDHD Assessment Request Form
Legal Name
*
First Name
Last Name
Preferred Name
First Name
Last Name
Gender Identity and Pronouns
Not required if you are not comfortable sharing.
Date of Birth (must be 18 or older for an assessment)
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter the best number to reach you.
Email
*
PLease enter the best email to reach you.
How do you prefer to be contacted
Email
Phone
Text
Why are you interested in being assessed for ADHD or Autism?
*
If we move forward with an assessment, what type of supports or accomodations should be included in the interview?
For example: parents, siblings, caregiver/other supportive person, pets, toys, tools, comfort items, etc.
Have you previously been assessed, tested, or evaluated? If so, please indicate an approximate date of the most recent time.
Would you be willing to sign a Release of Information so that I may review and compare with your previous results?
Please Select
Yes
No
Possibly. Will explain.
This is not a requirement. Declining to sign a release will not make you ineligible for an assessment.
Are you interested in a payment plan?
Yes
No
Other
Are you currently working with another mental health provider?
If you plan to use this screening or assessment for services with your current provider, signing a Release of Information is highly recommended unless you plan to provide the results to them yourself.
Are you interested in continued therapy services with this practice after the assessment and results are completed? (This is subject to clinician availability and other factors)
Yes
No
Other
Please upload a photo of the front and back of your insurance card if you would like us to review your benefits and see if an assessment will be covered.
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