Psychological Testing Contact Form

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Please fill out this form if you are interested in receiving psychological assessment services from Renewal Therapy.

Name of Person Completing Form *

Email *

Phone number *

I am interested in testing for:

Myself

My child or adolescent

Other:

Clear selection

Client's Date of Birth (if you are interested in getting services for your child or adolescent, please enter their DOB) *

YYYY

What kind of evaluation are you interested in?

Attention-deficit/hyperactivity disorder (ADHD)

Diagnostic Clarification/ Psychodiagnostic (i.e, differentiating between anxiety, depression, and other mood disorders)

I Am Not Sure

Other:

Clear selection

Please be aware that Renewal Therapy does not provide assessment services for custody evaluations, forensic issues, or other court proceedings. If you require such a service, please notify us and we will provide you with appropriate referrals. *

My assessment is NOT court-related and will be used for treatment and/or work or school purposes

I need a court-related assessment and would like outside referrals

Required

Please be aware that Renewal Therapy is only an in-network provider for Anthem/ Blue Cross Blue Shield Commercial Plans (we are NOT in-network with Anthem Healthkeepers Plus). If you have another insurance provider, you will be considered self-pay at Renewal Therapy. Please check one of the options below to indicate your understanding. *

Note: The all-inclusive self-pay cost of our comprehensive ADHD evaluation is $1385. If you have out of network benefits, you may be able to get a portion of the costs reimbursed by your insurance company.

I am in-network with Anthem/ BCBS and would like my assessment billed through my insurance. *Note: Depending on your insurance deductible, your out of pocket costs will range from $125 to $1100.*

I am in-network with another insurance company (e.g., Cigna, Aetna, or UnitedHealthcare etc.) and understand that I will be self-pay with Renewal Therapy.

I do not want to use my insurance for assessment services. I prefer to be self-pay.

I am in-network with another insurance company and would like referrals for in-network testing providers.

Required

Who referred you to Renewal Therapy?

My mental health care provider (e.g, psychologist, licensed clinical social worker, counselor, psychiatrist, or psychiatric nurse practitioner)

A friend or family member

My insurance company

Psychology Today

Facebook Post

An internet search

Other:

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If you were referred by a mental health professional please share their name below:

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