Admissions information sheet

Parent/Guardian #1 e-mail address*

Parent/Legal Guardian #2 e-mail address (if they wish to receive correspondence and results)

example@example.com

Preferred Phone*

Area CodePhone Number

Alternate Phone*

Area CodePhone Number

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please list the schools to which you would like results sent (if relevant). You can always call or email directly to add to this list.

It is not necessary to include Admissions contact information. Results are sent to you and to the school(s) simultaneously.

Please provide your consent to send results in the following formats*

emailfaxOther

I would like expediting if available (results within 4 business days) for an additional fee of $75.00 Please note that tester will confirm availability, as this feature is schedule-dependent.

YesNo

We do not test sick children. If your son or daughter is within the first 48 hours of taking a prescribed antibiotic, has a rash or viral infection, has vomitted or had a fever within 72 hours, or has any known COVID-19 exposure or possible COVID-19 symptoms, we require rescheduling. We are dedicated to finding a spot for you when your little student is feeling better!

If a school contacts us to discuss the test findings, we would like permission to do so. If you are agreeable, please indicate.*

YesNoOther

If you know, please indicate who will be accompanying your child to the appointment:

How did you hear of Washington Psychology Associates?*

Appointment status*

I have made an appointmentI have not made an appointment and need help

Parent's signature indicating acknowledgment of the policies reviewed in this document, truthful reporting, agreement to pay associated fees, and consent to evaluate:

Signature

Parent's full name

First NameLast Name

Please take a few minutes to complete this form.

Parent/Legal Guardian essentials