Psychological Testing Contact Form
Please fill out this form if you are interested in receiving psychological assessment services from Renewal Therapy.
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Name of Person Completing Form *
Email *
Phone number *
I am interested in testing for:
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Client's Date of Birth (if you are interested in getting services for your child or adolescent, please enter their DOB) *
What kind of evaluation are you interested in?
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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. *
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. *
Who referred you to Renewal Therapy?
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If you were referred by a mental health professional please share their name below:
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