ADHD/Autism Assessment

Interest Form

ADHD/Autism

First Name

Last Name

Zip Code

Phone/Mobile

Why are you seeking an evaluation for Autism or ADHD at this time?

What specific challenges or symptoms are you hoping to understand better through this assessment?

Are you looking for a diagnosis to pursue accommodations in a workplace or educational setting? If so, can you specify what type?

Are you seeking this assessment for personal insight, or do you have specific external requirements (like legal or disability claims) that need to be met?

Have you had any previous evaluations or diagnoses for Autism, ADHD, or related conditions? If so, what were they, and how have they influenced your current needs?

Are you currently receiving any mental health treatment? If so, what kind?

How do you plan to use the results of this assessment?

Are you aware that this assessment is for personal insight and may not meet the requirements for formal diagnoses needed for government-related purposes?

Do you have any specific expectations from the assessment that may not align with what an LCSW can provide?

Is there anything else about your situation that you think is important for me to know before proceeding with the assessment?

*ADD INFORMED CONSENT TO INCLUDE LIMITATIONS - WHAT DOES THIS MEAN EXACTLY?

Maybe something like I understand that completing this form does not guarantee that I will be booked for an Assessment?

ADHD/Autism Assessment

Interest Form

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