Evaluation Consultation Form

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This form is for inquiries related to comprehensive psychological testing for diagnostic purposes. Please fill out the form to express your interest in testing. You will receive an automatic confirmation that this form has been received. If we have any questions regarding the information you provided, we will reach out shortly. If we do not have any questions about the information you provided, our Evaluation Coordinator will call you to schedule your Intake appointment approximately 1 month in advance of the first appointment.

There is currently an 12+ month waitlist for child evaluations and a 3-5 month waitlist for adults.

Please note: We do not complete court mandated evaluations, military or employment screenings, or provide medication management.

This is not a crisis evaluation service. If you are experiencing severe mental health symptoms and are in need of immediate support, please call 911, call 988, or go to your local emergency room.

Click here to learn more about our evaluation services

Click here to set up ongoing mental health counseling services

Email *

First and Last Name of Potential Client: *

Date of Birth of Potential Client: *

YYYY

Pronouns of Potential Client:

School District or College of the Potential Client: *

First and Last Name of Person Filling Out Form: *

Your Relationship to Potential Client: *

Self

Biological Parent

Foster Parent/Legal Guardian

Caseworker

Other:

Phone Number: *

Email Address: *

Preferred Method of Contact: *

Phone

Please select which type of insurance you have from the list below. If you do not have one of our accepted insurance plans, please select the private pay option and we will get back to you with an estimated cost as soon as possible. Please note: we do not accept Medicaid or Medicare. *

CDPHP (Managed Medicaid Accepted)

MVP (Managed Medicaid Accepted)

Highmark Blue Shield of Northeastern NY

Private Pay (typically ranging from $1,250 to $1,625)

Please provide your insurance Member ID number or write N/A if you will be private pay. *

Please select one or more areas from the list below that you are interested in diagnostic testing for (you may select more than one option). Please note that this is not an exhaustive list of the evaluations we do or diagnoses we look at, this just gives us an idea of what it is you're looking for so we can best plan for your appointment. *

ADHD

General Mental Health (anxiety, mood disorders, depressive disorders, etc.)

Autism (for under age 15)

Early Childhood Developmental Concerns

Cognitive Functioning (IQ- Gifted or Intellectual Disability)

Other:

Required

We do not complete first time Autism Spectrum evaluations for individuals over the age of 15. If you are seeking a re-evaluation for services (including OPWDD) for Autism Spectrum and you are over the age of 15, please email documentation of your previous diagnosis to calbright@freedomfirstpsych.com as soon as possible.

Please provide a few sentences to briefly explain some of the concerns or reasons that the potential client is seeking a comprehensive diagnostic evaluation: *

If you have had a previous psychological evaluation, please provide detail below (including date and diagnoses): *

Are you interested in being contacted for a cancellation appointment (within less than 24 hours)? Please note that if you intend to private pay for the evaluation, you will be asked to provide full payment at the time of the intake appointment. *

Yes

*For Adult (18+) Evaluations Only* Are you interested in doing the initial appointment with the psychologist in person or via telehealth? Please note that all testing appointments will need to be completed in person. *

In Person Intake Only

Telehealth Intake Only

No Preference (Open to Either)

Not Applicable (Child Evaluation)

Our current waitlist is 8+ months for child evaluations and 5+ months for adults from the time of completing this form to the Intake Appointment with the Psychologist. Our Evaluation Coordinator will call you to schedule your Intake Appointment approximately 1 month in advance.

Our evaluation process is intensive. The whole process takes 2-3 months and includes a series of several appointments. The first appointment is the Intake Appointment with the Psychologist. This appointment will last an hour to two hours and will be a thorough interview regarding your background, symptoms, and experiences. After that appointment, the psychologist will decide on different assessments for you to complete. Some of these will be questionnaires regarding your symptoms, while others will be hands on testing with one of our testing assistants. There are typically 2-3 appointments consisting of these assessments and they range from an hour to an hour and a half in length. They are spread out over the course of several weeks based on availability of both you and our testing assistants.

After all the testing is completed, the assessments will be scored and written up in a comprehensive report that will include all the tests administered, any diagnosis (if applicable), and treatment recommendations. You may schedule an appointment to go over the results with the psychologist after you receive them if you wish to do so.

I have read and understand the above statement.

A copy of your responses will be emailed to the address you provided.

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