BonPsy Wellness Initial Inquiry Form

BonPsy Wellness Initial Inquiry Form
Thank you for your interest in our psychological testing services. To ensure we are the right fit for your needs, please fill out this brief inquiry form.

Please Note: We specialize in comprehensive psychological evaluations. Because we value quality and depth, we do not bill insurance directly. Please review the service details below before submitting.
Patient Information
Name of person being evaluated*

First NameLast Name
DOB*

MonthDayYear
Date
Patient Email (Leave blank if patient is a child)
example@example.com
Patient Phone (Leave blank if patient is a child)
Please enter a valid phone number.
Name of Person Filling out this Form
Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Communication Preferences & Consent
Please be aware that standard email and text messaging are not encrypted or a secure means of communication. While we take every precaution to safeguard your data, there is a risk that unauthorized third parties could access these messages. By selecting "Yes" below, you acknowledge these risks and permit us to communicate with you via these methods:*

VoicemailEmailSMS/TextSecure Simple practice client portal only
What type of testing are you interested in?*

ADHDLearning Disability; Dyslexia, Dysgraphia, or DyscalculiaBipolar Disorder, OCD, PTSD, GAD, DMDDPersonality Disorders (Borderline, Narcissistic, Histrionic, Avoidant)AutismGiftednessForensic: Court-ordered, child custody, etc.Medical: Pre-op clearance, spinal cord stim, surrogate, adoptionOther
If you selected other above, please elaborate:
How were you referred to our office? (doctor, therapist, school, self-referred)
Preferred Testing Format
Which format do you prefer for the testing sessions? Please note: The intake and feedback appts (appts 1 & 3) are always done via telehealth. The testing appointment (appt. 2) is lengthy and typically spans several hours.*

In Person: Mission Viejo LocationTelehealthNo PreferenceOther
Service Agreements
Please check the boxes below to acknowledge your understanding of our practice policies.*

Financial Policy: I understand that this practice does not accept insurance. I am responsible for the full fee out-of-pocket. I may request a "Superbill" to submit to my insurance for potential out-of-network reimbursement, but reimbursement is not guaranteed.Fee Acknowledgement: I understand the total fee for the standard ADHD evaluation is $2,500. (Usually split: 50% due at scheduling, 50% due at the feedback session). Add-on testing, such as giftedness, learning disability, etc., is subject to additional fees.Structure of Evaluation: I understand this process consists of three distinct appointments: Clinical Intake Interview (1 hour) + Testing Session (Several hours, in-person or telehealth) + Feedback Session (Review of results, recommendations) + ReportTimeline: I understand that high-quality testing is a detailed process. From the initial intake to the final written report, the process typically spans 4-6 weeks.Residential Requirements: I understand that due to licensing regulations, the patient must be a permanent resident of California AND physically located in California during the appointment.
Please select how you would like to handle the investment for this evaluation.*

50% deposit up front (Cash / Check / Zelle )50% deposit up front (Credit Card) = 3% processing feeFinancing: Cherry PayFinancing: Care Credit50% deposit up front + Payment planOther
Which type of documentation do you require for your records? Explanation:Standard Receipt: A simple proof of payment for your personal financial records or tax purposes. It does not contain clinical data.

I would like a Superbill. I intend to submit a claim to my insurance company for potential out-of-network reimbursement. I understand this document will contain a formal diagnosis and time-based CPT codes.I only need a standard receipt. I do not plan to submit a claim to insurance. A general proof of payment is sufficient.Other
Signature

Clear
Thank you for taking the time to complete this initial inquiry.

What happens next? Our team will review your submission and follow up shortly. Please make sure emails from "simple practice" and "bonpsy wellness" are allowed in your inbox.
Should be Empty:

BonPsy Wellness Initial Inquiry Form

Patient Information

Name of Person Filling out this Form

Communication Preferences & Consent

Preferred Testing Format

Service Agreements