North Lake Psychological Assessment Services LLC

North Lake Psychological Assessment Services LLC Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

Sex at birth

For insurance verification

Name the patient (you or your child) go by

Reason for care

What is the reason for seeking care?

Autism (or suspected autism) Attentional difficulties (or suspected ADHD) Learning differences in reading, writing, or math (or suspected differences) Memory, language, or other neuropsychological difficulties (or suspected issues) Intellectual/developmental disability (or suspected) Personality patterns or disorders Behavioral challenges Anxiety Depression Trauma or Grief Relationship/Family stress LGBTQIA+ support Other

If you have had a testing evaluation completed in the past, please briefly describe the results:

Limited to 600 characters

If you are receiving or have had therapy, psychiatric support, or other forms of treatment in the past, please briefly describe your experience:

Limited to 600 characters

Our work together will inform:

Disability services/government application A school IEP or 504 plan A legal matter (e.g., adoption, court order) Medication prescribed by another provider or practice Therapy Employment Daily living & relationships Other

Administrative

Referral source

How were you referred to our practice?

Client Preferences

Preferred appointment/contact times

Morning Afternoon Other

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, testing or payment questions, ADA accessibility needs, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.