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Therapy Request Form

Contact Information

First Name

Last Name

Preferred Name

Date of Birth

Legal Sex
FemaleMaleNonbinary

Gender Identity

Preferred Pronouns

Address

City

State

Zip

County

Phone Number

Your Email

Parent or Emergency Contact Name

Parent or Emergency Contact Phone Number

Relationship to Contact Listed Above

Insurance

Primary Insurance Provider

Member ID Number

Secondary Insurance Provider

Member ID Number

Clinical

What type of therapy are you seeking?
ERPEMDRIndividualPCITPlay AttentionFamilyOther
Specify therapy type:

What are your concerns and goals for therapy?

Are you requesting therapy with a specific clinician at PPLLC?
YesNo

What are your concerns and goals for therapy?

Availability

Do you prefer in-person or virtual appointments?
In-PersonVirtualNo Preference

What days are you available for an appointment?
MondayTuesdayWednesdayThursdayFriday

Do you have a time preference?
MorningAfternoonEveningOther
Specify time preference:

How did you hear about us?
Insurance CompanyPCPPsychological Perspectives websitePsychology TodayRecommended by a friendSchool DistrictSearch Engine (Google, Yahoo, Etc.)Social MediaOther
Specify how you heard about us/ who referred you.

Testing Intake Request Form

Contact Information

First Name

Last Name

Date of Birth

FemaleMaleNonbinary

Gender Identity

Preferred Pronouns

Address

City

State

Zip

County

Phone Number

Your Email

Parent or Emergency Contact Name

Parent or Emergency Contact Phone Number

Relationship to Contact Listed Above

Insurance

Primary Insurance Provider

Member ID Number

Secondary Insurance Provider

Member ID Number

Clinical

What type of testing are you seeking?

What are your primary concerns?

Have you had psychological/ neuropsychological testing in the past?
YesNo

If yes, what was the name of the evaluator / office and date of evaluation?

Availability

What days are you available for an intake appointment?
MondayTuesdayWednesdayThursdayOther
Specify days available:

Do you have a time preference?
MorningAfternoonOther
Specify time preference:

How did you hear about us?
Insurance CompanyPCPPsychological Perspectives websitePsychology TodayRecommended by a friendSchool DistrictSearch Engine (Google, Yahoo, Etc.)Social MediaOther
Specify how you heard about us/ who referred you.