Welcome to Neuropsychology
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- Merryl Byrd
- 5 years ago
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1 Welcome Welcome to Neuropsychology Calling the office Please let us know if you have any questions or concerns. If we are not available, please leave a voice mail and we will return your phone call within the next business day. Please turn off your Call Block or Anonymous Call Rejection features anytime you are expecting a return call from our office. Leaving information Our office uses a voice mail system. This system helps us to get back to you as soon as possible. To reach us for general questions, please call It is very important to give us the following information so we can use your child s chart when we return your call: Your name. Your child s first and last name and spelling of each. Your child s date of birth. Phone number where we can reach you. Patient liaison We can help you with travel and accommodation arrangements and can provide information on places to eat, shop and spend time with your family while in Fort Worth. Please call the Neurosciences department at to request assistance with accommodations, if needed. Neuropsychologists Marsha Gabriel, Ph.D. Beth Colaluca, Ph.D. Carla Morton, Ph.D. Neuropsychology 1500 Cooper St., 4th Floor Fort Worth, TX fax cookchildrens.org/neuro
2 Appointment checklist Dear parent or guardian: We recently scheduled an appointment for a pediatric neuropsychological evaluation for your child or dependent. Enclosed is a checklist and questionnaire for you to complete and bring to your visit. Our goal is to provide the best possible care to each patient we see. We encourage parents to ask questions, offer suggestions and participate in the planning of their child s care. Please use this checklist to help prepare for your child s visit. Complete the enclosed history forms and bring them to your appointment. Be sure our office has received all school testing, psychological and/or medical records related to the reason for your referral. If you attend Admission Review Dismissal (ARD) for your child at his/her school, please bring all of the following: The names of tests. The date tests were given. Overall scores and subtest scores. Eligibility category provided for IEP. Accommodations and modifications provided. Bring a current list of your child s medicines, including herbal and over-the-counter. Bring your insurance card and valid ID. Bring legal proof of guardianship. (Without this we may need to reschedule the appointment.) Divorced parents must provide a copy of full divorce decree with the judge s signature. Foster parent needs Texas Department of Protective and Regulatory Services (TDPRS) authorization forms. Grandparent needs written notice from legal parent with copy of divorce decree if parents are divorced. Grandparents with guardianship must have copy of guardianship papers with judge s signature. Step-parent needs written notice from legal parent with full copy of biological parent s divorce decree with the judge s signature. Arrive 30 minutes prior to your scheduled appointment. Allow enough time for any needed paperwork and/or the registration process. If you are late, your appointment may need to be rescheduled. You may also want to bring a sweater or jacket and a snack/drink. We provide reading materials in our waiting room and clinic, but adults may want to bring their own. Our waiting room also has WiFi available. Please fill in your appointment schedule below. Appointment day: Date: Appointment time: 24-hour notice is required on all cancellations. cookchildrens.org/neuro
3 Frequently asked questions What is child neuropsychology? Pediatric neuropsychology is a professional specialty that focuses on learning and behavior in relationship to a child s brain. What is a pediatric neuropsychologist? A pediatric neuropsychologist is a licensed psychologist with expertise in how learning and behavior are associated with the development of a child s brain structures and systems. The pediatric neuropsychologist uses formal standardized tests of abilities, such as memory and language skills, to assess brain functioning. He or she interprets the results based on what is expected at the child s age level and makes recommendations for optimal care. The pediatric neuropsychologist may also refer for such treatments as cognitive rehabilitation, behavior management and psychotherapy. At Cook Children s, neuropsychologists work closely with a team of neurologists and neurosurgeons, hematologists, oncologists and other physicians to provide appropriate treatments and interventions to meet the unique needs of each child. Where do I park? Visitor parking is located in the 7th Avenue Garage. What do I need to do if I can t make it to my appointment? If you are not able to make it to your appointment, please call our office at as soon as possible. We can then offer your appointment time to a patient on our waiting list. Our staff will reschedule your appointment on a day that will work better for your family. Please provide at least 24 hours notice for cancellations. What do I need to do if my insurance changes or is inactive? Please call our office if your insurance provider or policy changes or you have questions about your insurance coverage. What do I need to do if my phone number or address changes? It is important that we know how to reach your family by phone and by mail. Please call our office and let us know if your address or phone number changes. Our staff will update your child s records in our database. Our goal is to provide the best service possible. If you have any additional questions, call us at You may also send an from our website at: cookchildrens.org/neuro.
4 Billing information The appointment at our clinic is not a doctor s office visit. It is considered a hospital outpatient visit. This will be diagnostic testing based on your child s medical diagnosis. If you do not have insurance If you are not able to pay your bill in full, you can make arrangements with one of our customer service representatives at prior to your appointment. If you have insurance You may have a co-payment. Your insurance may apply all or part of your medical center charges to your deductible. If you have not met your deductible, you may have a balance due at the time of your visit. If you are not able to pay your bill in full, you can make arrangements with one of our customer service representatives at prior to your appointment. I have read, understand and agree with the above financial policy. I understand that charges not covered by my insurance, as well as applicable co-payments and deductibles, are my responsibility. I authorize my insurance benefits to be paid directly to Cook Children s Medical Center. I authorize Cook Children s Medical Center to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. Printed name Signature Date
5 Cook Children s Family/Visitor Parking and Drop-off Locations Directions to the 7th Ave. Garage Parking for Family and Visitors Traveling north or south on I-35W: Exit on I-30 and travel west. Take the Summit Ave./8th Ave. exit. Turn south on 8th Ave. Turn left on Pennsylvania Ave. Turn right on 7th Ave. The 7th Ave. Garage is on the left. Traveling east or west on I-30: Take the Summit Ave/8th Ave exit. Turn south on 8th Ave. Turn left on Pennsylvania Ave. Turn right on 7th Ave. The 7th Ave. Garage is on the left. N W. Cannon St. Cooper St. Summit Ave./ 8th Ave. Exit 3 Pennsylvania Ave. Thistle Hill Dodson Specialty Clinics 2 I-30 7th Ave. Garage Cook Children s Medical Center 6th Ave. Pruitt St. Downtown Fort Worth I-35W Drop-off locations with valet parking service 1 Medical Center Main Entrance W. Terrell Ave. 8th Ave. Urgent Care 7th Ave. 1 ==== Emergency Entrance 2 3 Dodson Lower Level Entrance for Dodson Surgery Center and Outpatient Radiology Dodson Specialty Clinics Entrance Southland St. Ronald McDonald House th Ave.. Terrell Ave. Garage W. Humbolt St. 6th Ave. S. Lake St. 5th Ave. Henderson St. Pulaski St. Pulaski St. Rosedale Ave. Building Entrance Visitor Parking Valet Parking ==== Temporary Road Closure (set to reopen in mid-march) Cook Children s Medical Center Seventh 7th Ave., Ave., Fort Fort Worth, Worth, TX TX Medical Medical Center Center Parking Parking 4/13 1/14
6 Date: Neuropsychology developmental questionnaire Patient s name: Age: Family composition Individuals living in household (Please include step-parents, roommates, partners) Parents or siblings outside of household Member Age Relationship Member Age Relationship Parents current marital status: Parent occupation: Place of employment: Education: Parent occupation: Place of employment: Education: Medical and developmental history The information you furnish is held in confidence. Please answer in the blanks provided. 1) Was child adopted? If so, at what age? 2) Date of last hearing test? Normal? 3) Date of last vision exam? Normal? 4) Current health problems? 5) Up to date on vaccinations?
7 Neuropsychology developmental questionnaire Date: Please check if anyone in your family (parents, grandparents, siblings, aunts, uncles) has ever had any of the following problems: Mother s Side Father s Side ADHD (attention problems/hyperactivity): Learning disorder: Depression/suicide: Anxiety/excessive worry: Obsessive compulsive symptoms: (e.g. excessive hand washing, checking, performing rituals) Panic attacks: Alcohol/drug use: Schizophrenia: Bipolar disorder (manic depression): Problems with the law: History of seizures: Autism: Tourette syndrome/tics: Pregnancy history 1) Length of pregnancy: 2) List medications taken during pregnacy: 3) Check any of the following that were present during your pregnancy with this child: High blood pressure Use of nonprescription drugs Drinking alcohol Bleeding Smoking cigarettes Nausea Headaches Accidents Swelling Infections Convulsions Diabetes Anemia Vomiting 4) Birth weight of child: 5) Please describe any complications which occurred during delivery:
8 Neuropsychology developmental questionnaire Date: Infancy and early childhood 1) Was the child a cuddly baby? Irritable baby? 2) At what age did your child? Sit alone: Crawl: Walk: Speak single words: Speak several words together: Toilet train: 3) Which best describes your child s development (check one): Slow Fast: Normal 4) What is your opinion of your child s intelligence: Average Below Average Above Average 5) Additional comments: 6) Has your child received physical therapy? When? 7) Has your child received occupational therapy? When? 8) Has your child received speech therapy? When? 9) Has your child ever had (check all that apply): Seizures or convulsions? Head Injuries? Memory problems? Coordination problems? Discipline 1) Has child ever been physically abused? Sexually abused? School history 1) Name of present school: Grade: 2) Is the child in Special Education/ARD meetings? If yes, which service: Resource: Content mastery: Behavior improvement: ECI: Alternative school? 504? 3) Has the child ever repeated a grade? If yes, what grade(s)? 4) How many schools has your child attended?
9 Neuropsychology developmental questionnaire Family problems which may be affecting your child Recent or multiple moves? Custody dispute? Parental separation or divorce? Financial stresses? Family violence? Health problems? Conflict between parents? Psychiatric illness? Drug or alcohol abuse? Death in the family? Remarriage or new partner? Absence of parent? Other treatment 1) Has your child had previous counseling? Psychological or Neuropsychological Testing? Medication for behavior problems? If yes, what agency or individual treated him/her? Comments: Signature of person completing form Relationship to child Date
10 Medication history (please include any herbal or regular over-the-counter medicines) Patient Name: Completed by: Date: Name of medication Route Reason Date started Effects of medications Date stopped Tylenol 200mg By mouth Migraines 3/10/14 None 3/20/14 Please list allergies to any food and/or medicines:
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39 th and Market Street, Penn Presbyterian Medical Center, MOB 340 Philadelphia, PA 19104 215-662-9775 823 South 9 th Street, 1 st Floor Philadelphia, PA 19147 267-239-2725 Last Name First Name MI SS#
Student Information: Student Name: Date of Birth: Grade:
Kelly STEAM Magnet Middle School, 25 Mahan Drive, Norwich, CT 860-934-1101 John B. Stanton Elementary School, 386 New London Turnpike, Norwich, CT 860-934-1107 Teacher s Memorial Global Studies Magnet
Initial Clinical History and Physical Form
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Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)
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Evergreen Behavioral Health Psychiatric Intake Form. Name: Date: Date of Birth:!
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Moms Help Organization Helping Moms to be the best Moms they can be! West Sample Road, #24 Coral Springs, FL
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*Please feel free to ask your child s doctor for help with filling out this form or contact our 22q Center Nurse at
Child s Name Today s Date Parent(s)/Guardian(s) Child s DOB Age Address Phone Parent s email Who is completing this form (name and relation to patient) Insurance Provider Subscriber s Name Subscriber ID
Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA ( ) NEW CLIENT INFORMATION
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Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
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HD CLINIC MEDICAL HISTORY FORM
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Evergreen Speech & Hearing Clinic, Inc. Transforming Lives Through Improved Communication Since 1979
Audiology Hearing Testing VRA VNG/VEMP OAE BAER/ECochG Hearing Aids Cochlear/Bone Implants Tinnitus CAPD EHDDI Speech-Language Pathology Language Voice Accent Modification Autism Evaluation & Treatment
Cy-Fair Hearing Aids Case History Form. Brandy R Jacobson Au.D. PERSONAL INFORMATION. Patient Name: Appointment Date: Date of Birth: Age: Gender: Male
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Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
Journey to Truth Counseling
ADULT / COUPLE INTAKE FORM (Please Print) Date: / / Social Security # Date of birth: Age: Mr. Ms. Dr. Mrs. Miss. Rev. Full Name (Last) (First) (Middle) Parent/Guardian/Power of Attorney: (if applicable)
Personal Disclosure Statement and Notice of Practices
Sound Therapy of Seattle Lisa Gormley-Leinster, M.A., LMHC, NCC, CCMHC 200 1st Ave West, Seattle, WA 98119 Phone: (206) 659-1738 www.soundtherapyofseattle.com soundtherapyofseattle@gamil.com Personal Disclosure
Home Sleep Test (HST) Instructions
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USF Eye Institute and Ear, Nose and Throat Center Pediatric Eye Clinic Welcome to the Pediatric Eye Clinic at the University of South Florida! I am glad that your child is coming to visit me at the University
Name Age Relationship to patient
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Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
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CENTER ON DEAFNESS 3444 Dundee Road Northbrook IL / TTY 847/ FAX 847/
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PATIENT REGISTRATION FORMS
Today s Date: Preferred Office: Trevose Newtown Warrington Northeast Horsham PATIENT INFORMATION Patient s Last Name: First Name: Middle: Nickname: Date of Birth: Age: Gender: Student: Part Time Full Time