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Please note that we currently do not have a psychologist on staff who is conducting psychological evaluations, and are not scheduling assessments at this time.
Assessment information form
I understand that this form is only to be used for requests for Psychological or Educational Testing, and that WellSpring will be unable to respond to requests for therapy appointments or other services. I understand that under no circumstances should this form be used in emergency situations, as it is not a reliable avenue for help. If this is an emergency, please dial 911 or go to your local emergency room. Thank you.
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I acknowledge that I have read an understand the above statement
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Indicates required field
Name
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First
Last
Phone Number
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Email
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This assessment is for:
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Myself
My Child
Other
I am seeking a:
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Psychological Assessment (e.g., ADHD, Autism, Mood or Anxiety Disorder, Behavioral Disorder, etc.)
Educational Assessment
Other
I have the following insurance:
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Anthem/BCBS/FEP
CareFirst
Tricare
Medicare
Other: My insurance is not in-network; I plan to self-pay for services
Comment
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Thank you! We look forward to speaking with you soon.
Submit
