Assessment and Evaluation Interest Form

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We are excited to see if we are able to provide an assessment or evaluation for you!
We have a few quick questions and then we will reach out and connect with you (you can expect a contact back within a week of submitting this form).

Just a reminder - We are currently scheduled 3-4 months from now. If you are interested in referrals or to be on our wait list, please feel free to fill out the form.

Name

Pronouns

Phone number

You have a choice when it comes to how we communicate. Conventional Email (Gmail, Yahoo, Comcast etc) is inherently insecure. Additionally if you use a work email to communicate your boss or IT department may be able to read or know information you may not want them to know. Know that we at Dr. Sanderson and Associates only use secure communication through Luxsci that covers my G-Suite program. When I email you it will be encrypted. But it may not be when you email me directly from your email program. If you wish to not leave your email, we will contact you by phone.

One of the two options below must be selected for me to follow up and communicate with you: *

I understand that conventional email is inherently insecure and therefore poses a risk to the privacy and security of my Protected health information. I accept these risks and consent to Dr. Sanderson and Associates communicating to my unsecured email with regards to scheduling, billing, and payment for healthcare services. I am not required to give this consent in order to receive treatment.

I only wish to be contacted via secure communications means, or at the phone number provided, until such time as I may elect to make a request for communication via non-secure means at a later date.

Where did you hear about us?

Psychology Today

Another Professional

Other:

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