Adult Form

Adult Testing Intake Form

When filling out this form, please be as specific as possible. Include dates and other detailed information where applicable.

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By typing my initials in this box, I consent to sharing my child’s personal medical and psychological history with Cognitive Solutions Learning Center, Inc. and its employees.

I understand that all information will remain confidential, and not be shared with anyone outside of Cognitive Solutions Learning Center, Inc. without prior written consent:


Please describe any of the following problems you have experienced, including the time of onset for each: