Appointment Request Form

Appointment Request Form

You may also email us at Referrals@AtlantaPsychological.com with any questions. We are unable to schedule appointments via email or electronic means only.
Date*

MonthDayYear
Date
How did you find us?
Please specify name of referring person/agency and profession, if known.
(For example, Dr. Smith - ABC Surgery Center)
Which clinician are you requesting to see? (if known)*
What appointment needs do you have?*
If you need to schedule or reschedule an appointment that is to take place in the next 24 hours, or the next business day, please call our office. For emergencies, please call 911.
What type of evaluation is needed?
(i.e., psychological, psychoeducational, neuropsychological, etc.)
What type of court-related evaluation is needed?
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Gender Identity
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Client or Parent/Legal Guardian E-mail*
Parent/Legal Guardian's Name (if applicable)

First NameLast Name
Check all that apply for the patient:

Acculturation problems (i.e., language barriers, interracial couples, family, 1st/2nd generation immigrants)Attention problems/hyperactivity (ADHD concern)Bipolar disorder concernsChronic medical problems (i.e., pain, diabetes, sleep problems, headaches, etc.)Developmental delays (i.e., cognitive, speech, motor, language, possible Autism)Educational or learning problemsEmotional concerns (i.e., anxiety, depression, anger)Family conflictGender identity development (i.e., transgender, gender non-binary, genderqueer, LGBTQ+, genderfluid)General behavior concernsBehavioral problems for elderly (i.e., elopement, persecutory delusions, scatolia, etc.)Legal problemsNeed to determine what kind of treatment is needed for mental health issues.Need to determine if there is a mental health diagnosis.Obsessive compulsive behavior/OCDParenting difficultiesSchizophrenia/psychosis concernsSubstance use problemsTrauma/Post-Traumatic Stress Disorder (PTSD)Other
Are there any other special considerations or reasons for the requested appointment?
Can the appointment be via phone or video conferencing if possible?*
Name of person to contact for scheduling (if not the client or a legal guardian).

First NameLast Name
Best phone number for scheduling the appointment:*

Area CodePhone Number
What is the above person's relationship to the client (for scheduling purposes)?
Name of person completing this form, if not the client or a legal guardian.

First NameLast Name
If you are not the client, what is your relationship to the client?
What days work best for an appointment?

MondayTuesdayWednesdayThursdayFriday
What time works best?

MorningAfternoon
By signing and submitting this form, you give the clinicians and employees of Atlanta Psychological Services permission to call you for scheduling. You are also certifying that all information provided in this form is true and correct to the best of your knowledge.

Contact us via phone at 770-457-5577 with any questions or problems about this form.
For identification verification, please upload a photo of your picture ID
Client Signature / Legal Guardian's Signature*

Clear
Should be Empty: