Secure Contact Form - Testing Accommodations

Secure Contact Form (HIPAA Compliant)

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High-Stakes Testing Accommodations Evaluation Inquiry Form

Thank you for reaching out. To best assist you, please complete the information below.

Exam You Will Be Taking

MCAT

LSAT

BAR EXAM

USMLE

OTHER

pls specify below

pls specify here

Nature of Evaluation Request

I HAVE received academic or testing accommodations in the past and need a re-evaluation

I HAVE NEVER received academic or testing accommodations in the past and am seeking initial evaluation

I was DENIED accommodations and need a second opinion evaluation

Other

pls specify below

pls specify here

Please indicate any additional info you think might be helpful, if applicable (optional)

Email address

Do you consent to us responding to you via secure email?

Yes

This consultation request form does NOT create a doctor patient or other client relationship and is for informational purposes only. It is not to be used for any urgent or emergency mental health needs. In the event of urgent mental health needs, including thoughts of harm to self or others, please go to the nearest emergency room for an evaluation and/or contact your local emergency services (911) or call the crisis hotline at 988.

Yes I understand and agree to the above.

Your information will be encrypted.

High-Stakes Testing Accommodations Evaluation Inquiry Form

Amica Clinical Consulting PLLC

www.amicaclinicalconsulting.com

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