Psychological Testing Contact Form
Please fill out this form if you are interested in receiving psychological assessment services from Renewal Therapy.
Sign in to Google to save your progress. Learn more
Name of Person Completing Form *
Email *
Phone number *
I am interested in testing for:
Clear selection
Client's Date of Birth (if you are interested in getting services for your child or adolescent, please enter their DOB) *
MM
/
DD
/
YYYY
What kind of evaluation are you interested in?
Clear selection
Please be aware that Renewal Therapy does not provide assessment services for custody evaluations, forensic issues, or other court proceedings. If you require such a service, please notify us and we will provide you with appropriate referrals. *
Required
Please be aware that Renewal Therapy is only an in-network provider for Anthem/ Blue Cross Blue Shield. If you have another insurance provider, you will be considered self-pay at Renewal Therapy. Please check one of the options below to indicate your understanding. *
Required
Who referred you to Renewal Therapy?
Clear selection
If you were referred by a mental health professional please share their name below:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Renewal Therapy. Report Abuse