Psychological Evaluations
Full Name (Please complete for the person who will be evaluated)
*
First Name
Last Name
Date Of Birth (DOB)
*
-
Month
-
Day
Year
Date
Sex
*
Please Select
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Full Name of Legal Guardian (if applicable)
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Requested Evaluation (please select all that apply)
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Forensic Assessment
Personality Assessment
Bariatric Assessment
ADHD Assessment
Learning Disability/IQ Assessment
ADHD/Learning Assessment
Autism Assessment
Other
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.
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Virtual
In Person
I am open to either
Reason For Assessment (please select all that apply)
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Court Ordered
Educational/Accomodations
Personal Reason
Medical Clearance
Referral from a healthcare provider
Other
How did you find out about us?
*
Please Select
Social Media
Word of Mouth
Court Referral
Internet Search
Other
Are you also interested in counseling services for the individual being assessed?
*
Please Select
Yes
No
Maybe pending results
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.
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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.
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Morning 6:00 AM – 12:00 PM
Afternoon 12:00 PM – 5:00 PM
Evening 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.
*
I agree
Please include any other information you would like for us to know:
Signature
*
Continue
Continue
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