Psychodiagnostic (Psychological Testing) Web SitePATIENT INFORMATION First Name * Middle Intial Last Name * Age * Date of Birth * Current Address * Apt or Suite # City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana IAIowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Your email address * Your phone number * Best time to reach you * Anytime Mornings (9am - 12pm) Afternoons (12pm - 5pm) Evenings (5pm - 9pm) Can I leave a message? * Yes No Is the patient a minor? * Yes No Who is requesting these tests? * Parent(s) School teacher Primary Care Physician Psychiatrist Neurologist Mental Health Provider School's Psychologist School's Nurse Other Health Coverage * Health Inusrance (PPO/HMO/EPO) Health Saving Account Medicare Medi-Cal No health insurance Medicare + Medi-Cal Cal Medi-Connect Reason for testing (please check all that apply): reason for testing_1 ADHD Autism Learning difficulties Cognitive issues Memory problems Behavioral concenrs Emotional disturbance Language disorder Conduct disorder Pre-surgery reason for testing_2 Intellectual disability Mutism OCD Phobia Panic attacks Sleeping problems Paraphilia Narcisism Gaming addiction Social anxiety reason for testing_3 Depression Anxiety Schizophrenia PTSD Bipolar Eating Disorder Chronic pain Addiction Stress Other Appointment times: please chose at least three possible times that fit your schedule. I will contact you to confirm which of these times is available. First pick a day, then choose the time(s). Appointment time: First option Select a day Monday Tuesday Wednesday Thursday Friday Saturday Sunday select_day_3_first_option 7am - 10am 8am - 11am 9am - 12pm 10am - 1pm select_day_3_second_option 11am - 2pm 12pm - 3pm 1pm - 4pm 2pm - 5pm select_day_3_third_option 3pm - 6pm 4pm - 7pm 5pm - 8pm 6pm - 9pm Appointment time: Second option Select a day Monday Tuesday Wednesday Thursday Friday Saturday Sunday select_day_1_first_option 7am - 10am 8am - 11am 9am - 12pm 10am - 1pm select_day_2_second_option 11am - 2pm 12pm - 3pm 1pm - 4pm 2pm - 5pm select_day_2_third_option 3pm - 6pm 4pm - 7pm 5pm - 8pm 6pm - 9pm Appointment time: Third option Select a day Monday Tuesday Wednesday Thursday Friday Saturday Sunday select_day_2_first_option 7am - 10am 8am - 11am 9am - 12pm 10am - 1pm select_day_2_second_option 11am - 2pm 12pm - 3pm 1pm - 4pm 2pm - 5pm select_day_2_third_option 3pm - 6pm 4pm - 7pm 5pm - 8pm 6pm - 9pm Is this an evaluation for a legal proceeding? * No Yes Other Is there a deadline for these tests? * Yes No Is there anything else you would like to add to better assist you? this test only to make room