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Adult Intake Form
Adult Intake Form
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  • English (US)
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    Adult Intake Form

    Please tell us a little more about your concerns so we can better understand your needs for testing. If you have difficulties with this form, please call our office at 828-231-3297

    This form will take you approximately 15 minutes to complete, and is comprised mainly of checklists, allowing you to scan and complete quickly.

    The information submitted in this form is guaranteed to be kept confidential and secure. Please wait for the confirmation page to appear once you submit your form.


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    • Male
    • Female
    • Other
    • English
    • Spanish
    • Russian
    • Chinese
    • French
    • Arabic
    • Other
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    • Self
    • Spouse
    • Partner
    • Biological Parent
    • Adoptive Parent
    • Step Parent
    • Grandparent
    • Guardian
    • Other
    • Email
    • Phone
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    • Self
    • Spouse
    • Partner
    • Biological Parent
    • Adoptive Parent
    • Step Parent
    • Grandparent
    • Guardian
    • Other
    • Client is own legal guardian
    • I'm client's legal guardian
    • I have healthcare power of attorney
    • Other legal guardian or POA
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    • Huge
    • Large
    • Normal
    • Small
    Ok
    quoteCreated with Sketch.
    Ok
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    • Spouse
    • Partner
    • Biological Parent
    • Adoptive Parent
    • Step Parent
    • Grandparent
    • Guardian
    • Other
    • Email
    • Phone
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    • Yes
    • No
    • Not Applicable
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    (check all that apply)
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    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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    1 of 5
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    (check all that apply)
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    (check all that apply or none)
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    (check all that apply or none)
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    (Check all that apply or none)
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    (check all that apply)
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    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
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    (Previously diagnosed elsewhere)
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    (check all that apply)
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    (check all that apply and enter Birth Weight)
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    (check all that apply)
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    (check all that apply)
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    • Yes
    • No
    • Yes
    • No
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    1 of 5
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    (check all that apply)
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    1 of 9
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    (check all that apply)
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    Age Related Diseases
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    Neurodevelopmental
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    Mental Health
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    (check all that apply)
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    Thank you for completing this form. The information submitted is guaranteed to be kept confidential and secure. We will be in touch regarding options for testing, pricing, and scheduling soon. Please be patient as we review each intake form to make the best recomendations for the client. 

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