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Emory University Psychological Center (Emory University)

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Emory University Psychological Center

Evaluation Application Form – Ages 18 and older

Please complete the following screening form and fax or email to us (details below). Once we

have received this form, we may contact you by phone to conduct a follow-up interview. Based

on this information we will determine if we will be able to accept you for an assessment.

If you do not have enough room on this form, please feel free to include additional information

in your email.

Name: _______________________________________ DOB:________ Age: ____ Sex: ____

Mailing Address: ______________________________________

______________________________________

Best phone number at which to reach you: _____________________

OK to leave messages? Yes_____ No_____

School (if applicable):___________________________ Year in school: __________

Employment: _________________________________________________________________

What is the reason you are requesting an evaluation?

______________________________________________________________________________

Is the evaluation needed for any specific purpose?

______________________________________________________________________________

Please check any of the following that are concerns and briefly describe:

Attention: ____________________________________________________________________

______________________________________________________________________________

Academic Performance: ________________________________________________________

______________________________________________________________________________

Job Performance: ______________________________________________________________

______________________________________________________________________________

Depression: __________________________________________________________________

______________________________________________________________________________

Anxiety: ______________________________________________________________________

______________________________________________________________________________

Drugs/Alcohol: ________________________________________________________________

______________________________________________________________________________

Other: _______________________________________________________________________

______________________________________________________________________________

Have you had a previous evaluation? If so, when and by whom?

______________________________________________________________________________

_____________________________________________________________________________

Any medical issues? Medications? _______________________________________________

______________________________________________________________________________

Are you employed by Emory University? Yes____ No____

Is there anything else you would like us to know?

______________________________________________________________________________

Please email or fax your completed application to be considered for one of our clinician

openings.

Email: psytesting@emory.edu

This is an unmonitored email account. You will receive no communication from this email.

Fax: (404) 727-1284

We receive many more requests for testing than we have spaces for each semester. Availability

of assessment services is limited by the training needs of our students. If we do not have

availability or it is determined that other resources would be more helpful to you, appropriate

referrals will be provided. For additional information, please call (404)-727-7451.

Fee and Payment Instructions

If you are accepted for an evaluation, the full fee of $850 (which includes a non-refundable fee

of $100) is required to reserve your spot. Payments are made online (with a debit or credit card)

and must be received by our office within 1 week of your acceptance. We require two online

payments: a non-refundable $100 administrative processing fee, and a balance payment of

$750. The balance payment is automatically processed after the first evaluation session has

taken place.

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