Evaluation Appointment Form
This is for COURT ASSESSMENTS only
Patient Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Types of Evaluation
*
Substance Use
Anger Management
Mental Health
Sexual Related
Other
Please Select an Appointment Date
Session Type:
*
Please Select
Virtual
In-Person (Decatur)
Who referred you? i.e Dekalb County Court, Probation Officer, etc
*
Shorten Your Appointment Time By Uploading Your Court Related Documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional Notes
Secure Appointment
*
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( X )
Deposit (Non Refundable)
Please note: • The remaining balance is due before your assessment begins. • Final payment may be made by: • Exact cash (173) • Tap-to-pay (contactless card or mobile pay) • Zelle (send to: 470-939-2667) This policy ensures your appointment time is reserved and allows us to maintain availability for clients with urgent court deadlines. If you have questions or need to reschedule, please contact us at least 24 hours in advance.
$
25.00
Pay In Full (Discount)
Clients who choose to pay in full at the time of booking will receive a discounted rate of $190 for their assessment (regular price: $198). This option allows you to: • Save money by paying upfront • Skip the deposit step • Secure your appointment without any balance due on the day of your assessment This is a great option for those who want to simplify the process and save a little in the process. Please reach out if you have any questions or need help completing your payment! Note: Canceling the appointment will result in a refund less $25 required deposit.
$
190.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
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