Attention Assessment & Treatment Intake Form
Please complete this form to share attention-related concerns, current treatment status, and scheduling preferences for the intake process.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method
*
Email
Phone
Text Message
Assessment and Treatment Intake
Primary attention-related concern
*
How often do attention, focus, or task completion issues occur?
*
Never
1
2
3
4
5
6
7
8
9
Very often
10
1 is Never, 10 is Very often
Current treatment status
*
Not currently receiving treatment
Previously received treatment
Currently receiving treatment
Medication or therapy history related to attention treatment
Preferred treatment goals
*
Scheduling and Follow-Up
Preferred Appointment
*
Submit
Should be Empty: