Jill Forschler, LEP#3595 | Insight Learning Solutions

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Reason for care

What is the reason for seeking care?

What are your concerns for yourself/your child?

Attentional and/or Executive Functioning difficulties Developmental Disabilities (e.g. Autism, Intellectual Disability, ADHD) Learning Disabilities (e.g. dyslexia, dyscalculia, dysgraphia) Social Emotional Concerns (e.g. anxiety, depression, etc.) Other

What kind of evaluation is being sought?

Private assessment or IEE? If IEE, for which school district?

Administrative

Referral source

Enter how you were referred to our services

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.