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 NOT be able to fill these forms out online. You must first print a copy of the form on paper, then mail or bring the form to your school, therapist, nurse or doctor.
Click on the link below for the 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 files 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 IPAsThe 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.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. An insurance related form. ONLY used for clients that are using PacifiCare Insurance. Many of our CHIPA (College Health IPA) clients have PacifiCare insurance and must fill out this form several times throughout treatment. 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. An insurance related form. ONLY used for clients that are using PacifiCare Insurance. Many of our CHIPA (College Health IPA) clients have PacifiCare insurance and must fill out this form several times throughout treatment. GENERAL FORMS - All Clients
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: 1/28/08
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