Substance Use Evaluations are only offered virtually in Colorado at this time.

Our admin team will review your information and be in contact shortly.

For more information on our Substance Use Evaluations, check out our website.

First Name *

Preferred/Chosen Name

Last Name *

Pronouns

He/Him

She/Her

They/Them

Other

Date of birth *

Email *

Phone *

I am filling this out for an individual that is not myself (ex. my child) *

Yes

No

Parent/Legal Guardian Full Name

Parent/Legal Guardian Phone Number

Reason for Seeking Evaluation: *

If other please specify:

I understand that this evaluation will not be billed to my insurance and will require out-of-pocket payment. *

I acknowledge and agree

The fee for a Substance Use Evaluation is $500. This amount will be charged to the card you provide two business days prior to your scheduled appointment. If the payment is declined or not successfully processed, your appointment may be rescheduled or cancelled. *

I acknowledge and agree to this payment policy.

I understand this evaluation is only for substance use concerns, including recommendations and diagnostic clarification. Evaluations for ADHD, ASD, or mood disorders are separate services. If I need both, I have completed or will complete the separate form on the website. *

I acknowledge and agree