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Client Intake Form
Please answer the following questions to help us with the intake process. It should take no more than 5-10 minutes. Once you've submitted the form below, we will be in touch shortly to schedule your testing date.
* Indicates required question
Email
*
Record my email address with my response
What is your child's name?
*
Your answer
How old is your child?
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Your answer
What school does your child currently attend?
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Your answer
Please type the name of all legal guardians.
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Your answer
What is the phone number for all legal guardians listed above?
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Your answer
What is the email for all legal guardians listed above?
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Your answer
What is the mailing address for the child?
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Your answer
Is your child insured by Medicaid (Health First Colorado)?
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Yes
No
Is English the primary language spoken at home?
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Yes
No
Who referred you to us?
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Your answer
Does your child currently have a 504, IEP or private school plan?
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Your answer
Has your child ever been tested before? Does your child have an established diagnosis (e.g. ADHD, anxiety, dyslexia, etc.)?
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Your answer
What are your main concerns/hopes for testing?
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Your answer
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