Psychoeducational Assessment Screener Form | Anxiety Specialists of Atlanta

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Psychoeducational Evaluation Screener Form

We appreciate that you are considering us to be part of your healthcare team.

This screener is for anyone caregiver or parent interested in a psychoeducational evaluation for your child or teen, between the ages of 6-16. If the request for new patient services is specifically for therapy or treatment services, please fill out “Child Screener” for someone under the age of 18, or the “Adult Screener.” for someone over the age of 18.

This screening process is in response to the high volume of requests we get for new patient appointments. We believe this briefer screener will increase our efficiency and accuracy in determining whether our clinic is an appropriate fit for your needs. We will do our best to match you with a professional whose background and availability address the information provided below. If we are unable to do so, we will do our best to provide you with appropriate referral resources.

For evaluations specifically, we specialize in assessments for ADHD, learning differences (e.g., dyslexia, dysgraphia, dyscalculia), giftedness, anxiety and mood-related concerns impacting school, school-based behavioral challenges, and screening for autism.

Please note: We do not offer custody evaluations, forensic assessments, or evaluations for court-mandated services nor are we are not an appropriate fit for individuals with self-harm, aggressive or defiant behaviors, substance abuse, severe neurodevelopmental disorders, or more serious mental illness.

For additional information about the disorders we treat, please visit our website.

Psychoeducational Evaluation Screener Form

Screening process for new patient appointments between the ages of 6-16.

"*" indicates required fields

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WAITLIST

Given the high volume or requests for new services, we are working off a waitlist system to best manage responding to all inquiries.

What does this mean for you? If you fill out the New Patient Screener Form, you will:
1) immediately be added to the waitlist
2) you will receive a notification, by EMAIL, that we have received your request for services and that you have been added to the waitlist, assuming your needs meet what our team offers (if you do not receive an email confirmation within one (1) business day, please contact our Practice Manager, Jessica Kalin, at 678-825-2320 by pressing 1.)
3) Once a spot is open, our intake coordination team will contact you by PHONE as soon as a space becomes available at the number you listed below. We will reserve that spot for 48 hours. If we do not hear back from you, we reserve the right to free up that spot for the next person on the waitlist.
4) If for any reason we will not be able to provide the services you have requested, we will do our best to contact you to offer referrals and other treatment options
5) For any additional questions, please contact the Practice Manager, Jessica Kalin, at 678-825-2320 by pressing 1.

YES, I have read this information understand that there is a current waitlist for available services

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Telehealth Services*

Please check to indicate that you understanding that treatment sessions are currently being held both via telehealth and in person. When visiting our offices in person, masks are required to enter our building, though they may not be required in the therapy session.

YES I have read the telehealth notification

Insurance*

Anxiety Specialists of Atlanta does not accept insurance, we are not in-network, but we are considered Out of Network (OON) providers. Therefore, every patient/family is provided all invoicing and superbills necessary to submit for claims. You can check with your insurance company to see what your OON benefits are and what your deductible is to start receiving reimbursement for OON services. Please check the box to confirm, YES, you understand this.

YES I am aware that Anxiety Specialists of Atlanta does not participate in any insurance panels, is only Out of Network, but does provide a superbill for me to file with my own insurer

Referral*

We may refer you to another practice or type of treatment following review of this screener or at any time after an intake has been scheduled if it is determined this would be the most appropriate clinical recommendation.

YES I am aware completion of this form does not guarantee my child will be evaluated by Anxiety Specialists of Atlanta.

If you have questions you'd like to discuss by phone, please contact our Practice Manager, Jessica Kalin, at 678-825-2320, but if you are calling for a new patient appointment, you must complete this form.

If this screener is being filled out by someone other than the Minor (THE PATIENT), please answer the following information, otherwise, Skip

Name*

First Last

Your relationship to the minor

Caregiver/Adult Phone Number*

Caregiver/Adult Email*

Personal Information for the Minor (The Patient)

Name of the Minor (THE PATIENT)*

First Last

Email of the Minor (if applicable)

Date of Birth of the Minor*

MM slash DD slash YYYY

Phone of the minor (if applicable)

Gender of Minor*

Male

Female

Non-Binary

Other

What is the minor's current educational setting? Please check all that apply.*

Public School

Private School

Virtual School

Homeschool

Homebound

The minor is not in school

Other

If the minor is in school, please provide school name and grade.

Primary language(s) spoken at home

Does the student currently have a 504 Plan or IEP?*

Yes- 504 Plan

Both 504 and IEP

Not sure

Other

Does the minor reside in the state of Georgia*

Yes

If the minor does not reside in Georgia, does he/she reside in any one of the other participating states that many of our therapists are legally permitted to provide telehealth services in, including Alabama, Arizona, Arkansas, Colorado, Connecticut, Commonwealth of the Northern Mariana Islands, Delaware, District of Columbia, Florida, Idaho, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, or Wyoming?*

Yes, the minor resides in one of the states listed above

No, the minor does not reside in one of the states listed above

What state does the minor live in from the options above?*

How did you find out about us? (Check all that apply)*

Internet search (e.g., google)

Referral from therapist or psychiatrist

Referral from other healthcare provider

Family member or friend

Professional organization search (e.g., IOCDF, ADAA, ABCT, ABPP, GPA, APA, etc)

Former or current patient we see

Referral from employer of school

Other

Name of Referral*

What concerns are prompting this evaluation request? (Check all that apply)*

Attention difficulties (e.g., possible ADHD)

Academic struggles (e.g., reading, writing, or math difficulties)

Evaluation for a learning disorder

Giftedness testing or academic placement

Behavioral challenges at school or home

Anxiety, mood, or emotional concerns impacting school

Social difficulties

Screening for autism spectrum concerns

School-based accommodations (504/IEP eligibility)

Private school admission or re-evaluation

Other

If there are other concerns, please describe them here:

Has the minor had previous testing?*

Yes (Please briefly describe when and where, if known)

If the minor has had previous testing, please share dates, and who conducted the evaluation.

Are any of the following currently concerns? (Check all that apply)*

History of developmental delays

History of trauma

Significant behavioral challenges (e.g., aggression or defiance)

History of psychiatric hospitalization

Current or recent self-harm or suicidal ideation

None of the above

Note: While we assess for emotional and behavioral concerns, we may not be the best fit if these are the primary reason for evaluation. Is there anything else you'd like to share?

Have there been any recent psychiatric hospitalizations, safety concerns, or substance use treatment in the past 3 months?*

Yes

If Yes, please describe

What are the main goals you hope to achieve from this evaluation?**

If we are able to offer an evaluation, how would you prefer to be contacted to schedule?*

Phone Call

Either is fine

Are there any questions we can answer for you by email regarding our services, policies, or procedures for new patients?

Newsletter*

Yes, I would like to subscribe to the Anxiety Specialists Of Atlanta newsletter/email updates

No, I would not like to subscribe to the Anxiety Specialists Of Atlanta newsletter/email updates

Thank for completing this screener. We will do our best to be in touch within 24 hours (1 business day).

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ABOUT
LOCATIONS
SERVICES
STAFF
RESOURCES
NEW PATIENT INQUIRIES
PATIENT PORTAL
- Sessions Health Patient Portal
- Appointment Check-In

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1360 Center Drive Suite 200
Dunwoody, Georgia 30338
Phone: 678-825-2320
Fax: 1-800-511-2741

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ABOUT
LOCATIONS
SERVICES
STAFF
RESOURCES
NEW PATIENT INQUIRIES
PATIENT PORTAL
- Sessions Health Patient Portal
- Appointment Check-In

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