ADHD & Autism Psychological Services PLLC

Instructions: Please enter the PATIENT'S information in the section below. Provide Patient’s email to be associated with the Patient Portal and notifications. When finished, click “Proceed to Registration” to create your username and password. The intake form will take 30-60 minutes to complete.

First Name:*

Last Name:*

DOB:*

Sex:

E-mail:*

Mobile #:*

Home Phone #:

Address:*

Zip Code:*

Patient Availability:

Days:

Sun Mon Tue Wed Thu Fri Sat

Reason for Visit:

Facility:

Get email instructions in:

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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