IMPORTANT! Please read these instructions before completing the forms!

 

1. Complete and bring with you to your first appointment all the following registration forms EXCEPT: Ace Scores Explained AND New HIPAA Confidentiality Notice. If this evaluator does not have all registration materials, completed, at the evaluation, then the evaluator cannot make a plan of treatment. You MUST bring all registration materials, completed, the first session, which is the evaluatory session.

 

2. If your first appointment is via telehealth (Zoom or Skype), then special instructions must be given to you for the submission of registration materials.

 

3. Please note: The forms, Current Caregiver Biographies, refer to you and your current partner/spouse or ex partner/spouse who helps you raise this child. This means 2 primary caregivers = 2 Current Caregiver Biographies and 2 Completed ACE quizzes.

 

4. Under no circumstances is a child or adolescent to fill out any of the registration materials.

Print & Complete

Children Registration Form Child's Biography Current Primary Caregivers' Biographies

The Caregivers ACE questionnaire ACE Scores Explained

New HIPAA Confidentiality Notice Signature Sheet for New HIPAA Confidentiality Notice

New HIPAA Release of Information Form   Neuro-Sensory Checklist

Texting and Email Policy Form

Download

These alternative forms are provided in Word format if you would prefer typing your answers.

Children Registration Form Child's Biography Current Primary Caregivers' Biographies