| 618-281-HEAL |
*Save time by printing and filling out these forms
before you arrive for your first appointment!
before you arrive for your first appointment!
Some of these forms may be filled out online, but must then be
printed. They cannot be saved or emailed. Sorry for the
inconvenience.
1. *Registration form
2. *Health History
3. *Consent to Treat
4. *Read the Privacy Policy and No-show Policy
and Phone Call Policy, and sign the form stating that
they have been read.
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5. Print and sign this Record Release Form if you
need us to get your records from your previous
physician.
6. Developmental Screening Forms
9 month
18 month
30 months
7. School Physical Form
8. ADHD- Parent Forms, Teacher Forms fill out this
form for new evaluation for ADHD and return to our
office at least 24 hours prior to your appointment. If
you can have more than one teacher fill this out, that
would be helpful as well.
9. Follow up ADHD- Parent Forms, Teacher Forms
10. Autism Screening- M-CHAT
11. Adolescent Forms-
Ages 11-14
Ages 15-18
12. Postpartum Depression Screening
printed. They cannot be saved or emailed. Sorry for the
inconvenience.
1. *Registration form
2. *Health History
3. *Consent to Treat
4. *Read the Privacy Policy and No-show Policy
and Phone Call Policy, and sign the form stating that
they have been read.
-----------------------------------------------------------------------
5. Print and sign this Record Release Form if you
need us to get your records from your previous
physician.
6. Developmental Screening Forms
9 month
18 month
30 months
7. School Physical Form
8. ADHD- Parent Forms, Teacher Forms fill out this
form for new evaluation for ADHD and return to our
office at least 24 hours prior to your appointment. If
you can have more than one teacher fill this out, that
would be helpful as well.
9. Follow up ADHD- Parent Forms, Teacher Forms
10. Autism Screening- M-CHAT
11. Adolescent Forms-
Ages 11-14
Ages 15-18
12. Postpartum Depression Screening
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Employment Application Our application process is always
open. Please print, fill out, and deliver the application by mail,
fax, or in person at your convenience. If you would like to know
about specific openings, feel free to call or email.
open. Please print, fill out, and deliver the application by mail,
fax, or in person at your convenience. If you would like to know
about specific openings, feel free to call or email.