Forms

Photo by Antonio_Diaz/iStock / Getty Images

Photo by Antonio_Diaz/iStock / Getty Images

At The Center for Behavior and Learning, we provide comprehensive neurodevelopmental evaluations for preschoolers through young adults. By completing the requested information prior to your first appointment, our providers will be able to focus your on your present concerns and questions about your child. You are welcome to mail or fax the forms in advance or bring the forms to the intake appointment.

Please ensure you complete the forms in all four steps including the psychologist specific forms at the bottom of this page.

It is also recommended that you review the written directions for our clinic location on our website prior to your visit to ensure timely arrival. GPS map programs often navigate to an incorrect destination.

 

 

Step 1 - Parent Forms

Please select the appropriate Parent intake form based upon your child's age.


 

Please select option A or B below

  • (A.) Preschool Questionnaire (Preschool and younger) - Parents or caregivers, please provide this form to the teacher(s) to complete in advance. Completed forms should be mailed or faxed to CBL by or prior to the first appointment.

 

  • (B.) School Age Questionnaire (Kindergarten and older) and DBD Rating Scale - Parents or caregivers, please provide these forms to the teacher(s) to complete in advance. Completed forms should be mailed or faxed to CBL by or prior to the first appointment.

Step 2 - School Forms

To obtain a comprehensive understanding of your child's needs, we require collateral information obtained directly from the school.

Please provide the teacher(s) with the appropriate age form(s) to facilitate informed assessment. Please ensure that you allow several weeks for the school forms to be completed by teachers and received by CBL.


Step 3 - Past Care Release of Information Form

If your child receives or has received psychological or psychiatric services from a different provider or clinic, please complete the following form for release of records. Please allow several weeks for clinic records to be released and received by CBL.

  • Medical Release Form Parents or caregivers, please send this form directly to the location your child received treatment in the past for release of records.


Step 4 - Center for Behavior and Learning Forms

In addition, each independent practitioner has individualized forms that are required by law to ensure that each family has the necessary information and understanding of psychological services. Please complete the forms for the specific psychologist that is scheduled on your provider only

DrHeatherForsyth.jpg

Heather Forsyth, PsyD, LP

  • Forms are provided in Dr. Forsyth’s Patient Portal with an email invitation after scheduling is completed

SS.jpg

Sarah Sander, PsyD, LP

  • Forms provided at intake

NS headshot 2 cropped (3).jpg

Nicole Schumann, PsyD, LP

  • Forms are provided in Dr. Schumann’s Patient Portal with an email invitation after scheduling is completed