Appointment Request Form
You may use this form to request an appointment or additional information. Our clinical staff will review your submission and respond to your request within one business day of receipt. Please
call or email
if you have any questions.
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Contact Details
Your Name
Preferred method of contact
Please select
Email
Phone
Text message
Mail
How did you hear about The Yellin Center?
Please select
Referral - Healthcare Provider
Referral - School/Educator
Friend or Family
Web search
Facebook/Twitter/Social Media Blog
Newsletter
All Kinds of Minds
Dr. Yellin - Presentation
Dr. Yellin - Media Appearance
Other
I would like to receive occasional email communications from The Yellin Center.
Yes
No
Student Information
Current educational level
Please select
Pre-K
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
College/University
Gap year program
Graduate studies
Medical school or residency
Law school
Not currently enrolled
Other
Current educational setting
Please select
Public school
Private school
Home school
Higher education
Has this student been evaluated for learning in the past?
Yes
No
For what reasons are you seeking an appointment at this time?
Comments or Questions
Please let us know if you have any other comments or questions at this time.
Submit
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