Forms

The following forms MUST be completed and signed:

I.

Contact Information

You MUST enter your contact information BEFORE proceeding

Child/Adolescent:
First Name:

Last Name::

Date of Birth:

Age::

Person Completing Form:
First Name:

Last Name:

Address Street 1:

Address Street 2:

City:

Zip Code: (5 digits)

State:

Daytime Phone:

Evening Phone:

Email:(required)

II. The Developmental Questionnaire is to be completed and submitted PRIOR to your initial appointment. If the questionnaire is NOT completed PRIOR to your appointment it will be canceled.

Please begin the process of completing the questionnaire by clicking on the link below:

ECA DEVELOPMENTAL QUESTIONNAIRE

III. The forms below provide information on our standard practice policy as well as our policy for deposit on evaluations. These forms MUST be printed out and signed.

Standard Policy

Policy of Deposit for Evaluation

IV. The forms below are for the purpose of release of confidential information. Each form MUST be printed out and signed.

Consent Form

Parent Consent to Treatment

V. The form below provides preliminary information on your child/adolescent's school experience. It MUST be printed out and completed by your child/adolescents teacher(s). Please printout the correct number needed.

School Questionnaire