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Dr. John Wager Psychological Services
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Intake form
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Name
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Email address
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What is your date of birth?
What is your gender?
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Male
Female
Non-binary
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What is your primary concern?
Please select at least one option.
Cognitive issues
Learning difficulties
Emotional concerns
Behavioral issues
School admission
Are you seeking services for yourself or someone else?
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Myself
Someone else
If seeking for someone else, please provide their relationship to you.
Have you previously received any psychological or neuropsychological evaluations?
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Yes
No
Please list any medications currently being taken.
Do you have any medical conditions that may affect evaluation?
Please provide any relevant family history of neurological or psychological conditions.
What are your goals for seeking evaluation or treatment?
Which service or services are you interested in?
Please select at least one option.
Comprehensive neuropsychological evaluations
Diagnostic & functional assessments
Psychoeducational assessments
Additional questions or comments
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