I certify that I am 19 years of age or older.

I certify that the medical information I have provided in this form and subsequent screening assessments is correct to my knowledge.

I authorize Alongside You and associated health professionals to collect my personal and medical information as documented below and in subsequent screening.

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists’ day that could have been filled by another patient.

As such, we require 48 hours notice for any cancellations or changes to your appointment. Patients who provide less than 48 hours notice, or miss their appointment, will be charged a additional fee to receive the 15 minute screening consultation.

You have chosen to undergo an screening to determine if what you experiencing suggests an assessment for ADHD is indicated as a reasonable course of action.

It is important to recognize that completing this screening does not guarantee that you should, or will be assessed for ADHD. Many challenges that may resemble ADHD—such as difficulties with focus, organization, or emotional regulation—can arise from other causes, including anxiety, depression, trauma, sleep disturbances, or various neurodevelopmental and psychological conditions.

Screening does not give a diagnosis. It indicates whether pursuing a diagnosis is suggested. This screening aims to clarify whether ADHD is a likely explanation for your experiences and pursuing an assessment is indicated.

This screening involves the following components:

Standardized ADHD Questionnaires: Self-report measures assessing attention, impulsivity, and hyperactivity.

15 Minute Feedback Session: After completing the screening, results and recommendations will be discussed with you, including whether further assessment for ADHD is an appropriate course of action.

The information you provide during this screening is confidential and will not be shared with anyone outside this practice without your explicit written consent. However, there are specific legal and ethical exceptions to confidentiality:

1. Risk of Harm: If you disclose an intent to harm yourself or others, we are legally required to take necessary actions to ensure safety.

2. Child or Vulnerable Person Protection: If there is suspicion of abuse, neglect, or exploitation of a child or vulnerable adult, we are obligated to report this information to the appropriate authorities.

3. Legal Requirements: If your records are subpoenaed by a court, we may be required to release relevant information.

4. Professional Consultation: We may consult with another registered psychologist for clinical guidance, but your identity will remain anonymous in such discussions.

Potential Benefits:

Obtaining a better understanding of your cognitive and behavioural functioning.

Clarifying whether pursuing an assessment for ADHD and diagnosis is indicated.

Potential Risks:

Some individuals may experience emotional discomfort when filling out screening materials or in their feedback session.

Screening does not provide a diagnosis and further assessment is required. Many factors that mimic ADHD symptoms (such as anxiety, depression, trauma, or sleep issues) may be more relevant to your experience. If ADHD is not indicated, alternative recommendations will be provided.

Screening results may impact self-perception, professional, or academic decisions.

Psychological screening can sometimes highlight areas of difficulty that may be distressing.

The cost of the ADHD screening, including screening materials and a 15 minute feedback session, is $100.

You will be charged $100 at the time of entering in your payment information and submitting this form.

You will automatically be given access to the online screening as soon as payment is processed. If there is a technical problem, you agree to contact us to ensure access for you.

There are no refunds for any reason once payment is processed unless we are unable to deliver screening to you.


Please note:

The screening service is not a service that is covered by insurance under psychological services.

You will receive a transaction receipt from our credit card processor at the time of the transaction, which will not be for insurance purposes.

If you decide to continue with a full assessment, the $100 cost will be deducted from your assessment cost, and a receipt for the remaining amount of the assessment will be issued for insurance purposes after completion of the assessment.

Your participation in this screening is entirely voluntary. You may withdraw at any time without penalty. However, if you choose to discontinue the screening, you are responsible for the cost of the screening and no refund will be given.

By signing below, you confirm that:

You have read and understood this consent form.

You have had the opportunity to ask questions and receive clarification.

You understand that an ADHD screening is not a diagnosis, or necessarily an indication of a need for more assessment, and that other explanations may better account for your symptoms.

You voluntarily agree to participate in this ADHD screening.