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 Code Phone Number

Alternate Phone *

Area Code Phone Number

Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Please list the schools to which you would like results sent. 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 *

email fax

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.

Yes No

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!

Please indicate that you understand that your child is required to wear a well-fitted cloth mask (not a gaiter, paper mask, shield, etc.) at all times during testing. Testing will not proceed without one and we encourage you to bring an extra mask to the appointment. *

Yes No, I have questions. Please contact me.

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

Yes No

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 appointment I 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

Clear

Parent's full name

First Name Last Name

Please take a few minutes to complete this form.

Parent/Legal Guardian essentials