Testing Sign-up & Interest form

Psychological Testing Center

Interest & Sign-Up Form
First name: *
Last name: *
Preferred/chosen name (if applicable)

Who is being assessed?
Are you inquiring for yourself or someone else? *

For myself For someone else (child, relative, etc.)

Full Name of Testing Individual: *

First Name Last Name
Preferred/chosen name of Testing Individual: (if applicable)
Your Relation to Testing Individual: *

Parent Child Other

Have you seen us before?
Are you an existing client? (Psychotherapy, Medication management, coaching/counseling, etc.) *

I am an existing client My child/spouse/relative is an existing client I am a new patient My child/spouse/relative is a new patient I was seen previously for services but am no longer My child/spouse/relative was seen previously for services but is no longer

Age
DOB: *

Month Day Year
Date

Sex/gender
Sex: *

Male Female
Gender Identity: *

Male Female Non-binary I prefer not to say Other

Contact info
Phone number: *
Email address: *

Home address
Street Address: *
BLDG/APT/SUITE #
City *
State *
ZIP code *

Type of Assessment
Please select the testing service(s) you are interested in: *

ADHD Full Psychological Profile Other

Please provide a brief summary detailing your concerns & goals for testing: *

Court/Legal Disclosure**
Are you required by law to complete this testing? [/or] Was this testing recommended to you for court/legal matters? *

YES, I am required to receive testing for court/legal matters YES, I was recommended testing for court/legal matters NO, this is NOT required or pertaining to court/legal matters

Scheduling Preferences
Preferred day(s) of the week: *

Monday Tuesday Wednesday Thursday Friday
Preferred time of day: *

Early morning (8:00 - 10:00) Late morning (10:00 - 12:00) Afternoon (12:00 - 3:00) Late Afternoon (3:00 - 5:00)

Anything else we should know?
Additional information/questions:
Should be Empty: