Evaluation Inquiry Form

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Today's Date *

YYYY

Client Name *

Name of person filling out the form if someone other than client *

Relationship to client *

I understand that evaluators at our practice are out-of-network providers. This means that we accept private pay for evaluations and your insurance company may reimburse you a certain percentage of the fees, if you have out-of-network coverage. Since every insurance plan is different, we recommend that you contact your insurance company directly to see if you have out-of-network coverage. *

Yes

I would like more information- To learn more, feel free to visit our Insurance + Rates page on our website.

I understand that the payment for an evaluation is due in-full at the initial evaluation appointment *

Yes

I would like more information- Before your appointment is scheduled the cost of the evaluation will be reviewed with you in order to ensure you are aware of all costs

Is the client currently seeing a NYBH therapist for therapy? *

Yes

Has the client seen a NYBH therapist in the past? *

Yes

Client Age *

Client Date of Birth *

YYYY

Home Address *

Gender *

Male

Female

Gender variant/Nonconforming

Transgender Female

Transgender Male

Prefer not to answer

Other (please list below)

Other:

If you chose Other in the prior question, please explain

School Name or Occupation *

Email *

Phone *

Referral source *

website

internet

Another client of NYBH

NYBH therapist

Another provider (doctor, therapist, etc.)

School or Tutoring center

Other:

If your referral source was another provider, school, or tutoring center, please list their name below. *

Preference for location *

Garden City

New York City

Virtual evaluation (only available for adult ADHD evaluations)

What type of evaluation are you inquiring about? *

Psychological

Psycho-educational

IQ test

Academic testing

ADHD

Learning Disability

College accommodations

Behavioral

Bariatric Surgery Evaluation

Work Fitness

Employment testing

Law enforcement evaluations

Other:

Required

Therapists at NYBH are able to assess for diagnoses and provide letters if needed. If you are interested in pursuing treatment beyond your assessment of symptoms and don't require any formal report or use of formal testing (IQ, academic, neuropsychological) Please indicate yes below and do not submit this form. We are better able to assist you if you complete our therapist match request form https://www.newyorkbehavioralhealth.com/find-your-therapist/ *

Yes

If you are seeking an evaluation in order to receive college accommodations, does your school require specific tests or the use of standardized IQ and academic tests in order to consider your qualification for accommodations *

Yes

I am not sure

If you answered yes to the question above, please explain what is required below

Presenting problem/reason for seeking evaluation *

Submit

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