Initial Inquiry Form for Adults

Instructions

Please provide us with the following information so that we can determine how to best proceed in scheduling appointments and evaluating your child. All information provided will remain confidential. All sections must be completed. Write “N/A” in any blank that is not applicable.

Client Name

First Name

Last Name

Client Phone

(###)

###

####

Client Email

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current Occupation

Services you are seeking (Please select ONE)

comprehensive neuropsychological evaluation

ADHD and Executive Functioning Clinic

Learning Disability and Dyslexia Clinic

Autism Screening Clinic

Transition Planning Consultation

Tell us about your concerns.

Please provide a brief description of the concerns you have about your learning, emotional functioning and/or behavior. Include any relevant medical or learning diagnoses from the past or present.

How did you learn about Dr. Schmidt’s services?