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

Primary/Parent Guardian

Primary Parent/Guardian First & Last Name

Relationship to Patient

Primary Parent/Guardian Date of Birth

Phone

Email address

Primary Parent/Guardian’s Marital Status

Does the child live with this parent/guardian?

Other Parent/Guardian

Other Parent/Guardian First & Last Name

Relationship to Patient

Patient Address

Street Address

Apt, Suite, etc.

City

State

ZIP/Postal Code

INSURANCE INFORMATION

Insurance

Effective Date

Group #

Member ID

Payor ID

The member ID is the unique ID your insurance company uses to identify your account. May also be called Member ID

The payor ID is generally a 5 digit number that is unique to each insurance company

Policyholder's Name

Policyholder's Date of Birth

Relationship to Patient

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

Your information will be encrypted.