Please complete the form(s) prior to your visit. 

Option 1: Print out the pdf and complete by hand
Option 2: Type in the fillable Word form - Enable editing and complete on computer - Save it and print it out

Patient Form (pdf)                                    Patient Form (Word)

Relative/Friend Form (pdf)                   Relative/Friend Form (Word)

Parent/Guardian Form (pdf)                Parent/Guardian Form (Word)

So that we can fully evaluate your medical needs, please fill out our Patient Form and bring it with you at the time of your initial appointment.

If a relative or friend who is a primary person in your life is coming with you to the visit, please have them complete a Relative/Friend form and bring it with them at the time of your appointment. It will be helpful during your evaluation. 

or Child Evaluations: 

Parent/Guardian: Please complete the Parent/Guardian Form and answer the questions regarding your child. This should be completed from YOUR perspective of the child. Also, if you are a biological parent or biological guardian, please fill out a Patient Form regarding yourself and your history.  Psychiatric illnesses, if they are present, are medical illnesses that can be inherited. Environmental factors can also play a key role. The family history almost always helps the doctor to begin to determine the student’s diagnosis and therefore family history is a critical starting point. While family members frequently protest filling out the Patient Form prior to seeing doctor, they invariably appreciate filling out the form after they have met with him. During the evaluation the Patient Form will be used to understand family history and environment. It includes ADHD, anxiety and depression inventories.

Child: If the child is 12 or over, have the child complete the Patient Form themselves. If the child is 7-11, please complete the Patient Form with the child.  Read the questions to them, explaining the questions as needed, and complete the form with the child’s answers.  Some questions may not apply to this age group. Please write “Not Applicable” where appropriate. If the child is under 7, please complete the form for the child.  Some questions may not apply to this age group. Please write “Not Applicable” where appropriate.

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