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Appointment request

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Contact details

Full name *Phone number *Email address *Best way to respond *

What are you looking for?

Assessment selected: IQ & achievement / learning disability evaluation

Service *Care format *Preferred clinicianInsurance or paymentInsurance ID # OptionalDate of birth Optional

Preferred timingSelect any that work, then add a date or details if helpful.

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Brief note Do not include diagnoses, medical records, or other sensitive health information.

This request is not an appointment confirmation. Submitting opens your default email application with the information above; review it before sending. Email may not be secure, so insurance ID and date of birth are optional. You may call 877-505-8130 to provide them instead.

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This form is not monitored for emergencies. Call 911 or go to the nearest emergency department. Call or text 988 for the Suicide & Crisis Lifeline.