ADHD Assessment Screening
Name of Person to be Assessed
*
First Name
Last Name
Preferred Name (if different from above)
First Name
Last Name
Age of Person to be Assessed
*
Grade Level of Person to be Assessed
*
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
College
Other
Please Explain
*
Reason for Assessment? (Choose all that apply)
*
Academic
Therapeutic
Other
Please Explain
*
1st Parent/Guardian Name
*
First Name
Last Name
2nd Parent/Guardian Name
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How Do You Prefer to Be Contacted?
*
Email
Phone Call
Text
How Did You Hear About Us? (ex., friend, web search, doctor)
*
Submit
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