GoodLife | Psychological Services

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Adolescent Assessment

Registration Form

Testing Center / Branch *

Assessment Type *

Adolescent Information

First Name *

Middle Name

Last Name *

Suffix

Nickname

Date of Birth * (MM / DD / YYYY)

Sex *

Preferred Pronouns

Please specify your pronouns

Address *

Contact Number *

Religion/Faith Tradition

Languages/Dialects Used

School

Grade / Year Level

Please specify

Assessment Info

Reason for Consultation *

Emotional concerns

Behavioral concerns

Anxiety/fears

Sadness/depression

Self-harm

Family concerns

Trauma/stress

School/academic concerns

Attention/concentration

Social/relationship difficulties

Psychological assessment

Therapy/counseling

Diagnostic clarification

Others:

Referral Source

Please specify (Other Referral Source)

Current Living Arrangement *

Please specify (Other Living Arrangement)

Create Login Credentials

When creating the username and password please follow the format: Lastname+BirthYear (e.g., Cruz1999)

Note: The username and password should be the same.

Username *

Password *

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