Evaluation Request Form
Thank you for considering us for your testing and evaluation needs! Please complete this form to begin the intake and scheduling process.
CLIENT INFORMATION
Please provide information about the client (who is being tested).
Client name:
*
First Name
Last Name
Client date of birth:
*
Client age:
*
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email (if a minor, provide parent/guardian email)
*
example@example.com
Phone Number (if a minor, provide parent/guardian info)
*
Please enter a valid phone number.
Format: (000) 000-0000.
INSURANCE INFORMATION
Client's primary insurance carrier:
*
Name of policy holder: (Whose name is on the insurance card?)
*
First Name
Last Name
Member ID Number:
*
Policy number:
Group number:
Insurance policy effective dates:
Provide the phone number on the back of your card:
Has the client received this type of testing before? If so, when? Please describe what the findings or results were.
*
Is there a secondary insurance? If so, provide the name of the insurance carrier, member ID, the name of the policy holder, and the phone number on the back of the insurance card.
*
EMERGENCY CONTACT INFORMATION
Provide information for the person you want listed as your emergency contact.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
COLLATERAL CONTACT INFORMATION
Provide information for the person you want us to get information from. We will send online questionnaires to them asking about the client's symptoms. This can be a parent, spouse, teacher, or anyone else who knows the client well.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
EVALUATION TYPE
Type of Testing Requested (check all that apply)
*
ADHD
Autism
Learning Disabilities
Other
REFERRAL INFORMATION
Reason for referral/primary concerns:
*
Who referred you? This must be the name of a doctor or other professional.
*
First Name
Last Name
What agency or organization are they with?
*
Phone number of the individual who referred you:
*
Email address of the individual who referred you:
*
MEDICAL STATUS
Current Diagnoses, Medications, Treatments and Supports
*
Select all applicable challenges below for the Individual referred (check all that apply)
*
Learning challenges/poor grades
Sensory processing
Daily living skills
Hygiene
Impulsive Behaviors
Life Skills
Explosive behaviors
Theft
Nonverbal
Hearing impaired
Harming others
Behavior at home
Behavior at school
Self-Advocacy Skills
Self-Harm
Social Skills
Substance Use
Trauma
Sustainable employment
Uses a wheelchair
Truancy
Juvenile Justice/Court Involved
Has IEP or 504 Plan
Needs work accommodations
Needs IEP or 504 Plan
Board of Developmental Disabilities
Opportunities for Ohioans with Disabilities (OOD)
Needs college accommodations
Applying for disability income or support
Other
Please sign here to provide your Consent for testing:
Your name:
First Name
Last Name
Today's date:
-
Month
-
Day
Year
Date
Thank you! Please click Submit and we will be in touch shortly to get you scheduled.
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