Diagnostic Evaluation Intake Form

The following information is requested to help us to learn more about your child and your hopes for the evaluation process. The form covers many areas and can be completed in more than one sitting. If scheduled for an evaluation, you will also complete an intake where you can further discuss this information or share any additional information that you’d like us to know. The information you provide here will be stored securely in conjunction with HIPAA regulations. It is considered confidential and will not be released unless it leads to suspicion of child abuse, suspicion of elderly abuse, suspected intent on the part of the patient to harm himself/herself, suspected intent on the part of the patient to harm another individual, or if legally required to disclose information by a court or judge. If you have any questions regarding this intake form or confidentiality, please contact us at (773) 998-8500.

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