Assessment
in New York and Vermont

Testing with MindWell

Complete our brief questionnaire to share your testing needs.
Schedule your phone screen to review your needs, ask questions, and book your testing appointments.
At this time, we are unable to accept insurance directly for psychological assessment services due to full capacity. We understand that insurance coverage is important, and we are happy to provide superbills so clients can submit for reimbursement through your insurance provider.

Still Have Questions?

We’re here to support!

Your Assessment: Stop Wondering. Start Understanding.

Complete your confidential questionnaire to get started with MindWell's evaluation services.

Step 1 of 13 HIPAA Secure & Confidential

Get Started

Tell us a bit about who the evaluation is for.

Please note that MindWell Psychological Assessments is a self-pay service. You are responsible for all costs, even if you may be able to individually submit for partial reimbursement if your plan includes out-of-network benefits.

Is the evaluation for a minor or an adult? *

Minor: under age 18 Adult: age 18+

Select the type of psychological evaluation(s) you're interested in. *

ADHD Evaluation Autism Evaluation Psychoeducational Evaluation Developmental Evaluation (i.e., questions/concerns regarding development in early childhood for children under 5 years old)

Please contact your insurance company as reimbursement for these out-of-network services may be limited. Review MindWell's testing overview document for details.

Location & Scheduling

Where would you like to be seen?

Select the MindWell location closest to you *

Albany, NY Ithaca, NY Burlington, VT

Travel to Albany for testing Evaluations are conducted over a series of appointments: Intake session; Testing session; and Feedback session. Testing is completed in person at our Albany, NY office, while the Intake and Feedback sessions may be held via telehealth. Please check this box to acknowledge that you are willing to travel to Albany for the Testing appointment. *

Available during business hours MindWell's psychological evaluation services are scheduled Monday - Friday, during the hours of 8:30am - 4:00pm. Please check this box to acknowledge that you are available to schedule during these times. *

Which state are you located in? You must be located in either NYS or Vermont for any telehealth appointments. *

New York Vermont

Your Information

Tell us a bit about yourself.

Have you seen a MindWell provider in the past? *

Yes No

Your Legal Name (for insurance purposes) *

Email address *

Date of Birth *

Phone number *

- -

Home Address *

Child's Information

Tell us about the child being evaluated.

Has your child seen a MindWell provider in the past? *

No Yes

Child's Legal Name (for insurance purposes) *

Child's Date of Birth *

Home Address (child's primary residence) *

Parent / Guardian Information

Tell us about yourself.

Parent/Guardian Completing Form *

Your email address *

Your phone number *

- -

Custody Information

Required for treatment consent.

Are you the primary custodial parent/guardian? For minors, the custodial parent/guardian must consent to treatment. If there is shared custody, both parents/guardians are required to sign consent forms prior to the start of treatment. *

Yes No

Does the child have another legal parent/guardian? *

Yes No

Are they a custodial parent/guardian? *

Yes No

Reasons for Evaluation

Help us understand what brings you here.

Describe the reasons for seeking psychological evaluation services. Please include any considerations or problems that led to seeking an evaluation at this time. *

Do you have specific goals in pursuing this evaluation? *

Were you referred for an evaluation by another provider or individual? For example: therapist, teacher, pediatrician, other medical provider. *

Yes No

School & Accommodations

Currently attending school? (i.e., k-12 or college) *

Yes No

Received educational accommodations or supports, such as a 504 plan or an IEP? *

Yes, currently receiving Yes, in the past No, but currently seeking accommodations or supports No

Select all that apply *

IEP 504 Other

Safety Information

Does your child have previous or current involvement with Child Protective Services? *

Yes No

Has your child attempted suicide in the past year? *

Yes No

In the past year, has your child: had a psychiatric hospitalization; been admitted to an IOP or PHP; or been to the emergency department for mental health reasons? *

Yes No

Please fax the hospital intake and discharge records to MindWell's HIPAA secure fax at 607-241-9972 to the attention of Testing Services. Appointments cannot be scheduled until records have been reviewed. *

Acknowledged. I will fax records to MindWell's HIPAA secure fax at 607-241-9972.

Safety Information

Do you have previous or current involvement with Adult or Child Protective Services? *

Yes No

Have you attempted suicide in the past year? *

Yes No

In the past year, have you: had a psychiatric hospitalization; been admitted to an IOP or PHP; or been to the emergency department for mental health reasons? *

Yes No

Acknowledged. I will fax records to MindWell's HIPAA secure fax at 607-241-9972.

Insurance Information

For psychological evaluation services, MindWell is in-network with CDPHP, including CDPHP Child Health Plus and CDPHP Medicaid managed plans.

All other insurances are out of network. You will be provided with an estimate of self-pay fees upon scheduling.

Select the client's category of health insurance. *

CDPHP - In Network: The exact costs depend on your CDPHP plan, and any applicable deductibles, co-pays, or limitations CDPHP Child Health Plus or CDPHP Medicaid managed plans - In Network: Coverage and costs depend on your plan limitations, deductibles, or co-pays All Other Insurance Providers - Out of Network: Self-pay, you will be provided with an estimate upon scheduling Medicaid or Medicaid Managed - Out of Network: NYS Child Health Plus, Vermont Green Mountain Care, and Vermont Dr. Dynasaur (as primary or secondary) Medicare or Medicare Advantage - Out of Network: either primary or secondary coverage

MindWell is not able to accept Medicare, Medicare Advantage, or Medicaid insurance, as either primary or secondary coverage. This includes Dr. Dynasaur, Green Mountain Care, and NYS Child Health Plus. * *Please note that CDPHP Child Health Plus and Medicaid managed plans are accepted and in-network. CDPHP Medicare plans are out-of-network and not accepted. I would like to schedule as a self-pay client and understand that claims cannot be submitted to Medicare/Medicaid for reimbursement.

Insurance Details

Select the client's primary health insurance company *

Is the client covered by any Medicaid insurance? Select YES if there is ANY Medicaid coverage (primary or secondary). * Medicaid or Medicaid managed plans include: Dr. Dynasaur; NYS Child Health Plus; NYS Essentials Plan; Green Mountain Care; Medicaid Managed Care; Medicaid Fee-for-Service; Medicaid Advantage.

Yes No

Is the client covered by any Medicare or Medicare Advantage insurance? Select YES if there is ANY Medicare coverage (primary or secondary). *

Yes No

Policy Holder Information

What is the relationship of the primary policy holder to the client? *

Self Parent/Guardian Spouse

Name of the primary insured (the person whose name the policy is under) * If the client is not the primary insured, enter the name of the primary insured/policy holder. If the client is the primary insured select "self" in the previous question.

Date of birth of the primary insured *

Policy ID/Number *

Upload a picture of the front of your primary insurance ID card. If you are unable to upload your card today, there may be a delay in processing your request for services. jpg, png, or pdf files only

⬆ Choose File

Upload a picture of the back of your primary insurance ID card. If you are unable to upload your card today, there may be a delay in processing your request for services. jpg, png, or pdf files only

⬆ Choose File

Terms & Conditions

This form is secure and HIPAA-compliant. Your information is protected and used solely for the purpose of scheduling care.

MindWell's Terms of Use can be reviewed here: https://www.mindwellcenter.com/termsofuse

MindWell's Privacy Policy can be reviewed here: https://www.mindwellcenter.com/privacy

SMS Consent Message

By submitting, you agree to receive text messages at the provided number from MindWell Psychology. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT receiving messages at any time. For assistance with managing SMS communications, reply HELP. To OPT-OUT, reply "STOP" to any text message you receive from us.

I accept the Terms and Conditions. *

Schedule Your Phone Screen

Upon submission of your questionnaire, you'll be redirected to a calendar to schedule your phone screen. The phone screen is required as the next step of your request for evaluation services. Please do not skip this step or your request may be delayed.

During the phone screen you will speak with a member of the MindWell Assessment Team to answer your questions, review your evaluation needs, schedule your appointment series, and collect your deposit. In advance, please check your email to review important information and the MindWell Evaluation Overview document from assessment@mindwellcenter.com

I will schedule my phone screen on the following page. *

This form is secure and HIPAA-compliant. Your information is protected and used solely for the purpose of scheduling care.This form is not intended for urgent or emergency situations. If you or someone you know is experiencing a mental health crisis or emergency, please do not use this form. Instead, contact one of the following resources immediately: (1) Suicide & Crisis Lifeline: Call 988 or 1-800-273-8255 (2) Crisis Text Line: Text HOME to 741741 (3) Or go to your nearest emergency room.

Assessment
in New York and Vermont

Testing with MindWell

Still Have Questions?

Your Assessment: Stop Wondering. Start Understanding.

Get Started

Location & Scheduling

Your Information

Child's Information

Parent / Guardian Information

Custody Information

Additional Parent / Guardian

Reasons for Evaluation

Mental Health History

School & Accommodations

Safety Information

Safety Information

Insurance Information

Insurance Details

Policy Holder Information

Tell Us How You Found Us

Terms & Conditions

Schedule Your Phone Screen

Thank you!

Assessment in New York and Vermont

Testing with MindWell

Still Have Questions?

Your Assessment: Stop Wondering. Start Understanding.

Get Started

Location & Scheduling

Your Information

Child's Information

Parent / Guardian Information

Custody Information

Additional Parent / Guardian

Reasons for Evaluation

Mental Health History

School & Accommodations

Safety Information

Safety Information

Insurance Information

Insurance Details

Policy Holder Information

Tell Us How You Found Us

Terms & Conditions

Schedule Your Phone Screen

Thank you!

Assessment
in New York and Vermont