New Referral

Account

Client

Collateral

Presenting Issues

Consent

Schedule

Payment

Complete

Selected Service:

Comprehensive Child/Adolescent Assessment

Please choose how to proceed

To order services through this website you will be asked to create an account, or to log in if you already have one. Please continue with the questions below if you are ready to continue.

If you need further information, don't want to create an account, or need us to verify whether your insurance will cover the requested service please select "I need more information..." option below.

Please choose

I will continue and want to create a new account.

I already have an account and need to login.

Are the services requested related to any civil or criminal proceedings?

Yes

We are unable to take on this request.

Are you filling this out for yourself or for a minor whom you have legal authority?

Yes

Please note that you must be the legal parent or guardian for this person and/or have legal authority to authorize delivery of services. If this person is an adult they must fill out this form on their own behalf.

The person requesting services must be an adult submitting this request on their own behalf or on behalf of a minor who they have legal authority to authorize delivery of services.