ADHD and/or Autism Evaluation Request Form-Initial Contact
Hello!
In order to best serve you & schedule a consult call or find a good referral for you, please answer a few questions about what you're looking for at this time.

*Please note that while this information will be contained on a HIPAA complaint platform, the internet is the least secure way of sharing your personal information. For this reason, you may wish to keep any open ended answers general.
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About You
Tell us a bit about your diagnostic history & evaluation needs so we can best support you!
Full Name
Email
What are you hoping to get from this assessment *
Are you self-diagnosed? *
If yes, what is your self diagnosis?
Have you been evaluated before? *
If yes, please explain.
Please list any diagnoses you’ve received in the past, when you received it (year), noting if you feel they are accurate. *
Do you need formal work or school accommodations?  *
If yes, what kind of accommodations do you believe would be beneficial to you?
Are you seeking medication support?
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If yes, do you have a psychiatrist / psychiatric provider or are you in need of a referral?
Which of the following are you interested in: *
Required
Logistics
Tell us how you prefer to conduct evaluations
Do you prefer virtual or in-person session? *
The cost of an AuDHD Evaluation typically ranges from $800 (Informal Diagnosis Exploration) to $1600 (Full assessment & diagnostic written report). 

Is this financially feasible for you at this time?

 *
If the evaluation cost is not possible, please share what is possible. We hold a number of sliding scale spots every year. Please let us know if you'd like to be added to that list. 
Please let us know which payment options is best for you.(Insurance coverage does not include this service)
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Depending on your needs, ADHD &/or Autism Evaluations typically take between 3-6 hour long sessions. Are you able to commit to this length of process? *
 We schedule evaluation sessions weekly on Tuesdays from 10am - 2pm and Fridays from 12pm-3pm. Do you have availability to meet during these times?  *
Do you have any specific questions about the evaluation process or any information you'd like to share?
Would you like to schedule a consultation call?

*Consultation Calls gather more information and go over any additional questions you may have before proceeding to an intake. The call is 30 minutes and of fee of $75. 
 *
Thank You!
We'll be in touch with you within the next 3-5 business days. We'll schedule a consult call, schedule our first evaluation session OR if we're not the right people for the job, offer you some awesome referrals. Please look our for an email from amanda@balancedinwellnesstherapy.com 

For more information on what we offer, please visit us at www.balancedinwellnesstherapy.com
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