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.

Client's First Name:* 
Client's Last Name:* 
Client's Preferred Name:
Client's Pronouns: *
Client Phone Number (if 18 or older):
Client Email Address (if 18 or older):
Client's Date of Birth:* 
Client's Age:* 

Client's Grade (please enter "NA" if not applicable):*What's this?


Please enter either the client's current grade or their most recently-completed grade.

Client's School Name (or indicate if homeschooled, graduated high school, etc.):* 

Client's Gender:*

Person filling out this form:* 
Parent/Guardian 1 First Name:* 
Parent/Guardian 1 Last Name:* 
If the client is a minor, Parent/Guardian 1 will be our primary contact regarding this request for services.

Parent/Guardian 1 Day Phone:

Parent/Guardian 1 Cell Phone:  

Parent/Guardian 1 Email Address:*
Please Re-Enter Email Address: *

Parent/Guardian 2 First Name:
Parent/Guardian 2 Last Name:

Parent/Guardian 2 Day Phone:

Parent/Guardian 2 Cell Phone:

Parent/Guardian 2 Email Address:
Please Re-Enter Email Address:

All legal guardians are aware that psychological services are being requested for this client:* 

Legal parents are:* 

Who has legal custody of the student? (Check all that apply)*

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

Mental Health Insurance Provider:*

Note On Insurance

Belin-Blank Center psychologists are currently providers 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 current 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 client previously participated in counseling or therapy? If yes, when and with whom?
Has the client 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 client's cognitive and/or academic strengths?
The Assessment and Counseling Clinic does not offer forensic services. Are you requesting services to use as part of a legal proceeding?* 

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

Twice-Exceptional Assessment

Select this option if you believe the client 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 client meets criteria one or more psychological diagnoses, while also examining their pattern of strengths.

What's this?Due to our extensive waitlist, we are not currently accepting new therapy clients.

Individual Counseling

Individual counseling services are available for high ability and twice-exceptional clients 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 the client'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 clients in grades 7 through 9 who demonstrate strong intellectual and/or academic skills and social skills challenges (either due to Autism Spectrum Disorder 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?

Additional Comments: