Forms and Questionnaires
Below are copies of forms, letters and questionnaires to assist in managing and reporting information regarding yourself or your child. You will be able to fill some of these forms online. The paper forms must first be printed then mailed or brought to your school, therapist, nurse or doctor.
Online Forms are Listed in BOLD Print
Click on the link below for the paper form that you are looking for. When the form appears, use your Internet browser print command and print a copy of the form. After the form prints, use your browser "Back" button or command to continue.
These paper forms use the Adobe Portable Document Format (PDF)*. You must have a copy of the Adobe Reader installed on your computer. If you do not have this program you may download a FREE copy by clicking the "Get Adobe Reader" button below.
All Clients - For First Visit
General Intake Information
Managed Care Insurance Subscribers-
HMO,PPO,POS, or IPAs
(Paper Form)The administrative forms to be filled out on the first visit by all clients seeing therapists with Associated Therapists, Inc. These forms will allow us to set up your account in our system.
These forms are to be used by subscribers to a Managed Care, HMO, PPO, POS, or IPA insurance company.General Intake Information
Clients Without Insurance
(Paper Form)The administrative forms to be filled out on the first visit by all clients seeing therapists with Associated Therapists, Inc. These forms will allow us to set up your account in our system.
These forms are to be used by those clients that do not have insurance coverage.CHILDREN AND TEENAGERS - FOR FIRST VISIT
A rating scale developed by Dr. Amen to report symptoms a child or teen may be experiencing. Use this form on your first visit. A rating scale developed by Dr. Amen to report various symptoms such as anxiety, depression, anger, and attention difficulties. Use this form on your first visit. A questionnaire for teachers to report your child's behaviors in school. Use this form on your first visit. CHILDREN AND TEENAGERS
For teachers to report the progress of your child. Use this form if your child is on medication. Questionnaire for adults to help report the effects of medication on a child with ADD-ADHD. Use this form if your child is on medication. Daily or Weekly form for teachers to report behavior, academic and homework information. Use this form to help communicate with home and school. A form requesting and listing specific accommodations for an ADD-ADHD child in a regular classroom. A form letter requesting a school meeting for evaluation and determining appropriate accommodations for an ADD-ADHD child. The following letters are samples you may use or modify to communicate with a school district. Reprinted from the book: "The Complete IEP Guide: How to Advocate for Your Special Ed Child", by
Lawrence M. Siegel. Highly recommended if you need special services from a school district.
Order from Amazon.comA form letter requesting a child's entire school file from a school district. A form letter requesting that a school district send you information regarding Special Education procedures. A form letter formally requesting that a school district begin the evaluation and testing of your child. ADULTS
Jasper / Goldberg Adult ADD Screening Examination - Version 5.0. A rating scale for adults who may experience ADD symptoms. A rating scale developed by Dr. Amen to report various symptoms such as anxiety, depression, anger, and attention difficulties. Use this form on your first visit. GENERAL FORMS - All Clients
Online screening tests provided by www.psychcentral.com - an independent mental health social network. These test results are NOT sent to Associated Therapists. These screening tools do NOT diagnose any disorders. They are for you own use. You may discuss the results with your provider. View a comprehensive listing of the commonly used medications to treat ADHD in children and adults. Dosing information, main effects, adverse effects, and precautions are listed. Use this information only in collaboration with your physician. A HIPPA compliant form that authorizes the release of your confidential information to a specific person for a specific reason for a specific length of time.
Associated Therapists, Inc.
(714) 898-0362
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Page last updated: 4/19/10
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