Provider Consultation Request

Important Privacy Notice

Note: This form is not HIPAA-compliant. Please do not include any personally identifying information (PHI) such as the child's name, date of birth, address, school name, or parent/guardian contact information.

Step 1: Contact Information & Your Role

Provide your contact details and tell us about yourself.

Your Name (required)

Please enter your name.

Organization / Practice Name (required)

Please enter your organization name.

Email Address (required)

Please enter your email address.

Phone Number (required)

Please enter your phone number.

What is your role? (required)

Pediatrician Psychologist Psychiatrist Therapist / Counselor School Psychologist School Counselor Teacher / Educator Other Healthcare Provider

Please select your role.

What services are you interested in discussing? (required)

Guidance on whether a neuropsychological evaluation is appropriate Information about our evaluation process Discussion of a specific case (general, no PHI) Questions about appropriate referral pathways Other

Please select at least one service.

Consultation Preferences

Preferred Format (required)

Phone call Video consultation No preference

Please select a preferred format.

Preferred Timing

Weekday mornings Weekday afternoons Weekday evenings

Step 2: Areas of Concern

Select all areas of concern that apply to this child. (required)

Learning or academic challenges (e.g., reading, writing, math) Attention or executive functioning (e.g., planning, organization, impulse control) Emotional or behavioral concerns (e.g., anxiety, depression, defiance) Developmental concerns (e.g., delayed milestones, developmental delays) Social skills or peer relationships School support or accommodations (e.g., 504/IEP questions) Diagnostic clarification Not sure — looking for guidance

Please select at least one area of concern.

Additional notes or questions:

Step 3: Review & Submit

Almost done! Let us know how you heard about us, then submit your request.

How did you hear about our services? (required)

Web search Colleague referral Professional network Conference or workshop Other

Please select an option.

Request a Consultation

Important Privacy Notice

Step 1: Contact Information & Your Role

Consultation Preferences

Step 2: Areas of Concern

Step 3: Review & Submit

Message Received!

Request Received