ADHD Assessment Scheduling Info

First Name *

Last Name *

Phone *

Is this Assessment for you or someone else? *

Preferred Pronouns

e.g. she/her, they/them

Date of birth *

Email *

Address

Street Address

Country

State

City

Postal Code

Would you like to apply for A Sliding Scale and/or Payment Plan *

Yes

Preferred method of communication *

Parent/Legal Guardian First Name *

Parent/Legal Guardian Last Name *

Parent/Legal Guardian Phone Number *

Does the parent/legal guardian have legal authority to consent to healthcare services for the client? *

Are there any custody arrangements or legal restrictions that may affect consent for this assessment? *

Relationship to client *

Are you a current client of Ignite Pathways? *

Conners report scales before the appointment.

We will send the assessment reporting scales to you and your identified collateral informant(s) prior to your appointment. Please have these scales completed no later than the morning of your assessment or we may need to reschedule.

Self-report (ages 8+):

your email

School/Occupational (teacher, supervisor, colleague):

Supervisor/Teacher/Colleague email

Interpersonal/Home (parent, partner, roommate, friend):

Parent/Partner/Roommate/Friend email

Financial Responsibility & Billing Agreement

I acknowledge that I have read, understand, and agree to Ignite a Path to Wellness's Billing Practices and Financial Responsibility Agreement. I understand that I am financially responsible for all applicable charges associated with services provided, including private-pay and noncovered services, subject to applicable laws and insurance agreements. I understand that insurance reimbursement is not guaranteed and that I must request a superbill from Ignite a Path to Wellness if I wish to seek potential out-of-network reimbursement. I acknowledge that my insurance provider determines reimbursement eligibility and that Ignite a Path to Wellness is not responsible for reimbursement denials, delays, or determinations made by my insurance company.

Please check the box to the left if you agree and understand what is listed directly above.

HIPAA Privacy & Confidentiality Acknowledgment

I acknowledge that I have been provided access to Ignite a Path to Wellness's Notice of Privacy Practices, which explains how my protected health information may be used, disclosed, and safeguarded in accordance with HIPAA and applicable state and federal privacy laws. I understand that my information may be used or disclosed for treatment, payment, and healthcare operations as permitted by law. I understand my rights regarding access to, correction of, and protection of my health information. I acknowledge that Ignite a Path to Wellness maintains policies and safeguards designed to protect the confidentiality and security of my information in accordance with applicable legal requirements.

Please check the box to the left if you agree and understand what is listed directly above.

Bot protection

Parent/Legal Guardian Authorization I confirm that I am the parent or legal guardian of the individual receiving the ADHD assessment and that I have the legal authority to provide consent for healthcare services on their behalf. I certify that the information provided is accurate to the best of my knowledge. I understand that Ignite a Path to Wellness may request additional documentation to verify my authority to consent before proceeding with assessment services.

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Please sign below to acknowledge that you have completed this form accurately, truthfully, and to the best of your knowledge. *

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