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ADHD & Giftedness Assessments
Memory & Cognitive Aging Evaluations
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Cognitive Evaluations for Long COVID
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Contact Us
Home
About Us
Services
ADHD & Giftedness Assessments
Memory & Cognitive Aging Evaluations
TBI & Concussion Assessments
Recovery & Resilience Coaching
Cognitive Evaluations for Long COVID
Insurance & Private Pay Options
Press & Recognition
Contact Us
Cognitive Health Prescreening
Your responses are confidential and HIPAA-protected. This form helps us determine if our services are the right fit for your needs.
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Full Name:
Email:
Phone frustrated rules
Phone Number:
Preferred Contact Method:
Phone
Emai
State of Residence:
Briefly, what brings you in? (Optional)
What are you seeking support with?
ADHD or Giftedness Assessment
Memory or Cognitive Aging Evaluation
Concussion or TBI Evaluation
Recovery & Resilience Coaching
Long COVID Cognitive Evaluation
Second Opinion / Documentation Review
Not Sure—I'd like guidance
Are you currently involved in
*
Legal Case
Disability Claim
School/IEP Process
Workers' Comp
None
Have you been diagnosed with any of the following?
*
ADHD
Anxiety or Depression
Concussion / TBI
Autism
PTSD / Trauma
Bipolar Disorder
Psychotic Disorder
Memory Issues
None
Other
Are you currently seeing a mental health provider?
*
Yes
No
Do you feel that rules don’t apply to you or often get frustrated when challenged?
*
Yes
No
Anything else you'd like us to know?
Consent and Next Steps
I understand that submitting this form does not establish a treatment relationship and agree to be contacted to discuss next steps.
Submit
