Forms to download
New Patients
Demographics – under 18 (English) (Spanish)
Demographics- 18 and older
HIPPA- Privacy Practices Notice (English) (Spanish)
Patient’s Medical Surgical History Questionnaire (English and Spanish)
Pre-participation History and Physical Examination Questionnaire
Patient Policy (English) (Spanish)
Authorization for Use and Disclosure of Protected Health Information (English)(Spanish)
Established patients
Authorization for Medication at School
Demographics – under 18 (English) (Spanish)
Demographics – 18 and older
HIPPA- Privacy Practices Notice (English) (Spanish)
Patient’s Medical Surgical History Questionnaire (English and Spanish)
Academic and behavioral concerns
ADHD
Mutual Authorization ADHD Only (English) (Spanish)
NIHCQ Parent Assessment (Initial)
NIHCQ Parent Assessment Follow Up (Spanish)
NIHCQ Teacher Assessment Scale (Initial)
NICHQ Teacher Follow-Up (Informant)
Depression
PHQ-A (English) (Spanish)
SMFQ (4 – 10, to be completed by parent)
Anxiety
GAD-7 (11 and older, to be completed by patient)
PSC-17 (Pediatric Symptom Checklist)
Screen for Child Anxiety Related Disorder (SCARED) – to be completed by parent
Screen for Child Anxiety Related Disorder (SCARED) – to be completed by child
