ADHD Informational Session Interest Form

Complete the form below to be contacted by a team member within 24 business hours.

This evaluation is a self-pay, out-of-network offering, which requires payment via credit card.
This informational session is complimentary; you will not be billed until after the intake assessment and evaluation.

Patient First Name *

Patient Last Name *

Patient Birth Sex *

Patient Birthday *

Address *

City *

State *

ZIP Code *

Parent/Guardian Email *

Parent/Guardian Phone *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Yes, I am aware this program is self-pay & not covered by insurance. *