Forms
The following are forms that are commonly used in our office. We may refer you to this page to print or review forms for applicable appointments.
- New Patient Paperwork – We will ask you to complete these forms on your first visit to our office. You may wish to expedite your visit by completing them prior to your visit.
- Authorization for Records Release TO GUP – This form allows your child’s previous healthcare provider to share medical records with our office, ensuring we have a complete picture of your child’s health history.
- Authorization for Records Release FROM GUP – This form authorizes our office to send your child’s medical records to another healthcare provider or facility as needed for ongoing care.
- Anxiety Screening Children Form – The SCARED Child Screening gives children and adolescents a simple way to share how they have been feeling, helping us understand if anxiety may be affecting their daily life.
- Anxiety Screening Parent Form – The SCARED Parent Screening invites parents to reflect on their child’s emotions and behaviors, offering valuable insight into whether anxiety might be playing a role.
- Vanderbilt Parent Initial Screening for ADHD – The Vanderbilt Parent Initial Screening helps parents share observations about their child’s attention, behavior, and emotional patterns, offering a full picture of how their child is doing at home.
- Vanderbilt Teacher Initial Screening for ADHD – The Vanderbilt Teacher Initial Screening gives teachers an opportunity to describe how a child is focusing, learning, and interacting in the classroom environment.
- Vanderbilt Parent Follow-Up Screening for ADHD – The Vanderbilt Parent Follow-Up Screening helps track how your child’s symptoms and daily functioning may be changing over time.
- Vanderbilt Teacher Follow-Up Screening for ADHD – The Vanderbilt Teacher Follow-Up Screening provides ongoing insight into a child’s classroom progress and any changes in attention, behavior, or social skills.
- Sports Physical Form – The Sports Physical Form provides the information needed for your child’s school or sports team to confirm they’re healthy and ready to participate safely.
Our Notice of Privacy Practices is provided below for your reference. We do not need a copy of this for your records.
