Inquiry for ADHD + Autism Evaluation
Thank you for your interest in working with me, Courtney Hart, LCSW-C. 

This form has been intentionally created to to protect your time and energy, along with mine, as you search for the best fit for diagnostic evaluation for ADHD and Autism. 

Prior to completing this form, please read ALL of the information on the Diagnostic Evaluation page on my website, which answers many questions related to the process and outcome, by clicking here: https://www.healinghartwellness.com/evaluations

Once your form has been submitted to me, both you and I will receive a copy of your responses. 

Please allow up to one week for review. I will reach out to you via email regarding next steps. 

If you have difficulty with this form, please email hello@healinghartwellness.com for support. 
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Email *
Name of Person Completing Form *
How did you learn about diagnostic evaluation with me? *
Background Information
This portion reviews important information about the person being evaluated and your goals for the evaluation. 
Who is the diagnostic evaluation for? Referred to as 'evaluatee' in future questions.
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Required
Evaluatee's First and Last Name *
Evaluatee's Pronouns *
Required
Evaluatee's Date of Birth 
*I do not provide evaluations for individuals under 8, as detailed on my website.
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What state does the evaluatee reside?
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If evaluatee is a minor, all legal guardians are required to consent to their evaluation. Please identify your custody situation related to the minor below.
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What led to you exploring diagnostic evaluation and reaching out to me? 
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What are you hoping to get from this evaluation/what is your goal? Check all that apply and use "Other" for any additional information you'd like to share. 
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Required
If evaluatee is a minor, have they been informed that you are seeking evaluation for them and are they open to evaluation?
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Logistics
This portion reviews important logistical information related to services with me, Courtney Hart, LCSW-C, at Healing Hart Wellness, LLC. Please read each question carefully and respond with "yes" or "other." If you reply with "other," please write in as clearly as possible your answer. 
I am a Licensed Clinical Social Worker and therefore do NOT provide psychological, neuropsychological, or educational assessments. This evaluation is for diagnostics related to ADHD/Autism only and does not include IQ testing, testing for learning differences, etc. Does this work for you? *
I do not accept insurance at my practice. I operate using an equitable sliding scale for Diagnostic Evaluations, which can be reviewed on my website under the "Rates" page. Due to my licensure, your insurance company will likely not reimburse you for our work together, and if they do it will be limited. Does this work for you? *
Typically, diagnostic evaluations take about 4 weeks from first meeting/intake to our feedback session, although they can take up to 8 weeks at times. Does this work for you? *
If we are a good match, you will need to complete important surveys and assessments at least one week prior to our first meeting/intake. Does this work for you?  *
If we are a good match, you will need to complete important surveys and assessments at least one week prior to our first meeting/intake. Does this work for you?  *
Final Thoughts
Prior to submission of the form, please double check your email address is accurate above. If you do not hear from me within one week, please check your spam folder. 
Please use this space below to add any additional information that you'd like me to know or questions you may have about diagnostic evaluation with me. 
A copy of your responses will be emailed to the address you provided.
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