Assessment & Counseling Clinic

Request for Information

This form is to request information regarding clinical services (e.g., individual assessment, therapy, and consultation). If you are looking for information about educational programs and services for students, please do not complete the form below. Instead, please visit the following links:

Student Educational Programs and Services

A full list of the Belin-Blank Center's non-clinical services can be found here. Our programs include:

If you have additional questions about educational programs and services after viewing the information on our website, please call 800-336-6463 or 319-335-6148.

All information entered in the form below will be treated as confidential.

Student's First Name:* 
Student's Last Name:* 
Student's Date of Birth:* 
Student's Age:* 

Student's Grade:*What's this?


Please enter either the student's current grade or his or her most recently-completed grade.

Student's School Name:* 

Student's Gender:*

Person filling out this form:* 
Parent/Guardian First Name:* 
Parent/Guardian Last Name:* 

Home Address 1:* 
Home Address 2:
Zip Code:

Day Phone:

Cell Phone:  

Email Address:* 
Please Re-Enter Email Address: *

Mental Health Insurance Provider:*

Note On Insurance

Dr. Alissa Doobay is currently a provider for Blue Cross/Blue Shield. Clients also have the option of paying privately for services. Clients have the responsibility of contacting their insurance providers to determine coverage.

All financial aid slots for the 2019-2020 fiscal year have been filled and we are not accepting new financial aid applications at this time.

What are your current concerns? Briefly describe the reason(s) for your interest in services offered through our clinic.
Has the student previously participated in counseling or therapy? If yes, when and with whom?
Has the student previously received a psychoeducational or neuropsychological evaluation? If yes, when, where (e.g., school, private clinic, medical center, etc.), and with whom?
What are the student's cognitive and/or academic strengths?

I am interested in the following clinical services (check all that apply):*
What's this?

Twice-Exceptional Assessment

Select this option if you believe your student may have high intellectual or academic ability and concerns about specific areas of challenge (e.g., possible learning disability, attention disorder, autism spectrum disorder, mood or behavioral concerns, etc.). Twice-exceptional assessments involve determining whether a student meets criteria one or more psychological diagnoses, while also examining their pattern of strengths.

What's this?Private-pay only; no diagnostic testing or investigation of areas of concern. This is not a substitute for a twice-exceptional assessment.

Educational/Academic Assessments

Educational/academic assessments are conducted to assist with academic planning. They involve individual assessment of intellectual and academic skills. These assessments are not diagnostic in nature; therefore, they cannot be submitted to insurance for reimbursement. If, instead, you are interested in group-administered, above-level testing, please contact

What's this?

Individual Counseling

Individual counseling services are available for high ability and twice-exceptional students who may be experiencing challenges related to life transitions, stress, social relationships, a psychological diagnosis (e.g., anxiety, depression, ADHD, Autism Spectrum Disorder), and so on. Counseling services at the B-BC are provided by licensed psychologists, as well as advanced doctoral students under the supervision of a licensed psychologist.

What's this?


Consultations are one-time appointments that allow you to share your questions and concerns with a psychologist and request feedback. Consultations typically occur after an evaluation has already been completed. This may involve having a psychologist review your student's prior records (including evaluations from other providers) to generate recommendations, requesting assistance with a specific concern (e.g., responding to a recent incident of bullying), or determining the types of programs and services that may be beneficial for your family (e.g., counseling, re-assessment), etc. Consultation appointments are scheduled on an ongoing basis. Consultation fees are often not covered by insurance.

What's this?

Social Skills Group

The ACC's social skills intervention group is for students in grades 9 through 12 who demonstrate strong intellectual or academic skills and social skills challenges (either due to ASD or another diagnosis). Groups are organized periodically, and if you select this option, we will contact you when we are organizing the next social skills group session.

What's this?

Career Assessments

Career assessments are conducted with adolescents who would like support in making decisions about educational and career plans. The assessment includes measures of career interests and aptitudes, personality characteristics, and personal values. The counselor and adolescent then review and discuss the results of these assessments in relation to the adolescent’s general aspirations. The charge for this service is approximately $400; because this is not a medical expense, it cannot be submitted to insurance.

How did you learn about our clinic?

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