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Evaluation Forms

Select the appropriate form below to begin your evaluation process.

📋 Developmental Evaluation Intake

Comprehensive intake form for ADHD, autism, dyslexia, and other developmental evaluations. Provides detailed child and family information.

Use this for: Initial evaluation requests, developmental concerns, behavioral assessments

Complete Form

📊 Vanderbilt ADHD Assessment

An 18-item symptom checklist with numeric summaries. This partial form is not a complete Vanderbilt assessment and cannot establish or exclude a diagnosis.

Use this for: ADHD screening, behavior monitoring, treatment follow-up

Complete Form

🏫 Teacher Report Form

Allows teachers to submit behavioral and academic observations without needing EHR access. Covers academic performance, behavior, and social-emotional functioning.

Use this for: School-based observations, teacher input for evaluations

Complete Form

🩺 PCP Referral Form

For primary care physicians to submit referrals for developmental evaluations. Includes patient identifiers and referral information.

Use this for: Physician referrals, medical records requests

Complete Form

Important Information

📧 What Happens After Submission

  • Submitted information is sent to the clinic for review
  • Teacher reports and referrals may receive an automated acknowledgement
  • An acknowledgement does not confirm clinical review or an appointment
  • Contact the clinic to confirm receipt or discuss scheduling

🔒 Privacy & Security

  • Submit only information requested for the evaluation
  • Do not use these forms for emergencies or urgent medical concerns
  • Contact the clinic with privacy, access or record-correction questions
  • Ask the clinic about its privacy practices before submitting sensitive information

❓ Questions About Forms?

If you have questions about which form to use or need assistance, please contact us and our team will be happy to help.