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 myselfFor someone else (child, relative, etc.)

Full Name of Testing Individual:*

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

ParentChildOther

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

I am an existing clientMy child/spouse/relative is an existing clientI am a new patientMy child/spouse/relative is a new patientI was seen previously for services but am no longerMy child/spouse/relative was seen previously for services but is no longer

Age
DOB:*

MonthDayYear
Date

Sex/gender
Sex:*

MaleFemale
Gender Identity:*

MaleFemaleNon-binaryI prefer not to sayOther

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:*

ADHDFull Psychological ProfileOther

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 mattersYES, I was recommended testing for court/legal mattersNO, this is NOT required or pertaining to court/legal matters

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

MondayTuesdayWednesdayThursdayFriday
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: