Well Child Forms
*MCHAT (Autism Screening Tool)
*EPDS Postnatal Screening (to be completed at 2wk, 1 month and 2 month visit)
*Teen Depression Screening (to be done yearly by the PATIENT from 12yrs -18yrs old)
*Anxiety Screening (Parent and Patient portion at 11yrs and 14 yrs old well visit)
Scared Parent (Anxiety Screening-Parent part)
Some of the forms above are developmental and/or important screening forms that we use as a standard of care during certain well visits. These forms will be billed to your insurance for payment. In the event your insurance does not cover this screening, the patient will be billed $15 per form. Please note that some insurances cover these screenings but charge a copay to the patient.
New Patient Forms
Vaccine Information Sheets
Mental Health/Therapy Forms Safety Plan Therapy Consent Form LCSW Therapy Psy.D Informed Consent Therapy Release of Information Therapy Telehealth Consent
Please note: Vanderbilt forms are only for children ages 6 years and older.
School and Camp Forms
**Please get your forms from the school/daycare/camp requesting them and either mail, email or fax them to us. Please make sure your parent portion is completed, the child’s name is at the top of each page and the fee is paid to avoid any delays.When emailing or faxing a form for completion, please make sure the receipt of payment is attached or we will not be able to complete the form and email to: firstname.lastname@example.org or fax 301-990-0471Please allow 4 business days for the completion of any school or camp form.There is a $20 fee to fill out your form and an additional $15 rush fee to fill it out sooner than the 3-4 day normal time frame.We are happy to complete these forms free of charge if you bring them to your annual physical!Please make sure the name of the patient is on the form and the parent portion is completed before turning it in to our office. Please do not fill out the physician section and submit to us for a signature only. Doing so still results in a charge of the form fee as we still go over everything to be sure it is filled out correctly.Note: the extra $15 rush fee guarantees the form will be completed within 24hrs of when we received it. For forms received on Friday, we will guarantee the form by Monday for the rush fee. WE DO NOT GUARANTEE FORMS DROPPED OFF ON FRIDAY FOR SATURDAY OR SUNDAY PICK UP. Thanks for your understanding.
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