Appointment Request Form
Please fill out this form to request an appointment for your child. We look forward to meeting you!
Child First Name*
Child Last Name*
Have you already submitted this form for another child, or will you be submitting this form for another child?*
Yes
No
Parent/Guardian's First & Last Name*
Parent Email*
Phone*
Child Age*
Enter Child's Date of Birth in this format: YYYY-MM-DD*
Gender Identity*
Female
Male
Trans Female
Trans Male
Nonbinary
Other
Choose Not To Disclose
Preferred Pronouns
Primary Insurance Provider*
Primary Subscriber*
Insurance Member ID*
Primary Subscriber Date of Birth*
Sexual Orientation
Lesbian/Gay/Homosexual
Straight/Heterosexual
Bisexual
Unknown
Other
Choose Not To Disclose
How did you hear about us?*
Google Search
Word of Mouth
Facebook Ad
Referral
Provider Referral
Please select your primary reason for seeking an evaluation:*
Autism Spectrum Disorder
Learning Difficulties
Attention
Behavioral
Depression
Anxiety
Academic Challenges
Stroke
Traumatic Brain Injury
Memory Problems
Pre-Surgical
Second Opinion
Which type of evaluation are you seeking?*
Autism Spectrum Disorder
Learning Disorder
ADHD
Neuropsychological Evaluation
Pre-Surgical Psychological Evaluation
Independent Educational Evaluation (IEE)
Select additional reasons for seeking services below (check all that apply):
Anxiety
Depression
Relationship Issues
Substance Abuse
Family Conflict
Grief/Loss
Life Transition
LGBTQIA
Perinatal Support
Other
Stress Management
Communication Skills
ADHD
Autism Spectrum Disorder
Behavioral
Adjustment/Transition Difficulty
Which quality, if any, is most important to you in a clinician?
Gender
Life Experience
Years in practice
LGBTQIA+ Specialization
Secondary Insurance Provider (if applicable)
Secondary Insurance Member ID
Street Address (This is used to verify insurance eligibility.*
City*
State*
Zip Code*
Are you open to telehealth?
Yes
No
What is your preferred contact method?*
Phone
Email
Text
All of the Above
Preferred Appt Time
Mornings
Afternoon
Evenings
Weekends
Preferred Appointment Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Is this evaluation court-ordered?*
We will call you to learn more in order to match you with the best clinician. Is there anything else you'd like us to know?
Please verify your request*
Submit