Psychological Testing Waitlist: Age 26+

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Please complete this form to be added to our waitlist for psychological testing. Providers or parents may complete this form.

Wait Time: Once you submit this form, you will receive an automatic email confirming you are on the waitlist. Expect to wait 6-12+ months to receive a call from our office. NOTE: We prioritize scheduling of our youngest clients to ensure that they are receiving services in a timely manner. That means for most adults, they will likely wait closer to 12+ months before testing is scheduled. Please see our website for alternative options for psychological testing if you are curious in learning more about yourself.

Email *

Purpose of Evaluation (check all that apply) *

Access to treatment (e.g., medication or specialized therapy)

Approval of Social Security/Medicaid Disability

Standardized Testing Accommodations (e.g., GRE, SAT, Licensing Boards, etc.)

Curiosity about self (note: without impairment in daily functioning, this is not a medically necessary or covered expense by insurance)

Other:

Required

Date of Completion *

YYYY

Name of Person Completing Form *

Relation to Client *

Parent/Guardian

Primary Care Provider

Speech/Occupational/Physical Therapist

Other:

Client's First Name *

Client's Last Name *

Client's Date of Birth *

YYYY

Referral Concern (Check all that apply) *

Autism Rule-Out

ADHD

Developmental Delay

Personality Disorder

Psychosis (e.g., schizophrenia)

Mood/anxiety (note: best diagnosed through a strong therapeutic relationship with a counselor))

Other:

Required

Primary Insurance (If your insurance is not listed, we do not accept it, you may select self-pay)

(you must be located in the state that provider is licensed at the time of the appointment if it is virtual- TENNESSEE or MISSISSIPPI)

Blue Cross Blue Shield (Any State-Commercial, No BlueCare Medicaid)

Tricare

United Healthcare/UMR/GEHA (Commercial)

UHC Medicaid/MS CAN/MS CHIP (No UHC TennCare Medicaid)

Magnolia Medicaid

MS Medicaid (straight)

Ambetter (Commercial/Marketplace)

*Cigna clients using Optum for Mental/Behavioral Health please check here. (As of 10/13/23 We are no longer taking new Cigna clients for Psych Testing unless plan is connected to Optum)

Self-pay

What is your Primary Insurance Member ID #? (write none if you do not have insurance) *

Secondary Insurance (If your insurance is not listed, we do not accept it, you may select self-pay) *

None

UHC Medicaid/MS CAN/MS CHIP (No UHC TennCare Medicaid)

Magnolia Medicaid

MS Medicaid (straight)

We will not process secondary commercial plans. Check here to request a Superbill for the client to submit to secondary commercial insurance companies.

What is your Secondary Insurance Member ID #? (write none if you do not have insurance) *

Location for preferred testing *

Southaven

Clarksdale

Client's/Parent's Phone Number *

Client's/Parent's Email *

Any additional comments/questions:

A copy of your responses will be emailed to the address you provided.

Submit

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