Child Patient Paperwork

Step 1: ADHD Child Test

This test is not a comprehensive list of questions, but will give a good indication to the doctors whether further testing is needed to confirm ADD/ADHD symptoms.

Child's First Name & Last Name

Age

Patient Date of Birth

Please describe the issues your child is having.

How are these issues affecting his/her and your life?

CONTACT INFORMATION

Parent/Guardian Completing This Form

Upload Photo ID

Add file

Please upload a file

First Name

Last Name

Phone

Email address

Street Address

Apt, Suite, etc.

City

State

ZIP/Postal Code

Relationship to Child:

Biological Parent Adoptive Parent Legal Guardian Stepparent Other:

If other, specify:

Do you have legal authority to make medical and mental health decisions for the child?

Yes No Unsure

Parental Marital/Custody Status

What is the current marital or custody status of the child's parents?

Married Never Married Separated Divorced Widowed Other

Add new row

Please upload a copy or bring a copy to the first appointment

Add file

Please upload a file

I acknowledge that I may be asked to provide legal documentation regarding custody or medical decision-making authority.

Add new row

Final Checkbox for Consent

I certify that the information I have provided is accurate to the best of my knowledge and understand that false or incomplete information may affect the ability to provide care.

INSURANCE INFORMATION

Insurance Self Pay

Card ID (front)

Add file

Please upload a file

Card ID (back)

Add file

Please upload a file

Add new row

Have you had previous ADHD Treatment

If "Yes" above complete the following information.

Years on treatment

Are you still currently receiving treatment?

Reason for stopping meds.

Side Effects

Cost

Ineffective

Other

Didn't Need

Other Specified

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