New Evaluation Client Questionnaire
These questions will help our intake coordinator gather information as to which type of evaluation you are seeking and to help determine if we would be a good fit for you. We also use your answers to create a chart in our electronic health system should you decide to move forward with one of our evaluations. After you fill out this questionnaire, we will contact you within 24-48 business hours. Please note that we do not accept health insurance for evaluations. There is a space below if you would like us to check your out of network (OON) benefits. If you have any questions, feel free to call or text us at (925) 885-6070 or email us at info@aspireneuropsych.com
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Email *
Is this evaluation for yourself or for someone else? *
What is the first and last name of the person being evaluated? *
What is your phone number? *
INSURANCE
We don't accept insurance for evaluations however feel free to complete this section if you would like us to check your out of network benefits
Insurance carrier name
Member ID #
What is the patient's date of birth? (we use this information to check your benefits)
MM
/
DD
/
YYYY
Name and date of birth of primary subscriber
EVALUATION NEEDS/GOALS
What are you currently struggling with? *
What are your goal(s) for this evaluation? *
PREVIOUS DIAGNOSES/TREATMENT
Have you been previously diagnosed with a mental health condition by a professional? If yes, please list all previous diagnoses *
Is this your first time being evaluated? *
If your previous answer was no, please indicate which type of evaluation you have recieved in the past and the outcome.
Is there anything else that you would like us to know?
Please note that our clinicians are not crisis counselors. We encourage all clients to call 911 or go to their nearest emergency room if you are having a mental health crisis. Thank you for your time, we will be in touch shortly.
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