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Psychological Evaluations
Full Name (Please complete for the person who will be evaluated)*

First NameLast Name
Date Of Birth (DOB)*

MonthDayYear
Date
Sex*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Full Name of Legal Guardian (if applicable)

First NameLast Name
Phone Number*
E-mail*
example@example.com
Requested Evaluation (please select all that apply)*

Forensic AssessmentPersonality AssessmentBariatric AssessmentADHD AssessmentLearning Disability/IQ AssessmentADHD/Learning AssessmentAutism AssessmentOther
Are you looking to do virtual or in person? Please note that certain assessments cannot be completed virtually. Your preference will be noted for consideration where applicable.*

VirtualIn PersonI am open to either
Reason For Assessment (please select all that apply)*

Court OrderedEducational/AccomodationsPersonal ReasonMedical ClearanceReferral from a healthcare providerOther
How did you find out about us?*
Are you also interested in counseling services for the individual being assessed?*
Which days work best for you? Please note that selecting a preferred day does not guarantee availability; we will do our best to accommodate your schedule. You may select multiple days if more than one applies.*

MondayTuesdayWednesdayThursdayFridaySaturday
Which times work best for you? Please note that selecting a preferred time does not guarantee availability. We will do our best to accommodate your schedule. You may select multiple times if applicable.*

Morning 6:00 AM – 12:00 PMAfternoon 12:00 PM – 5:00 PMEvening 5:00 PM – 9:00 PM
I understand that all evaluations are an out-of-pocket expense. A deposit of $175 is required prior to intake for all assessments, except for personality assessments, which require a $100 deposit. Deposits are non-refundable.*

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Psychological Evaluations