Appt Form1 | MAPS

Appointment Request Form

Thank you for contacting MAPS Integrated Wellness division of Developmental-Behavioral Pediatrics! Please complete the following form to request an evaluation through our clinic. Thank you!

Who is completing this form?

Please know that services can only be provided with consent and a signature from the child's legal guardian.

Name:

Relationship to patient:

About Your Child

Child's Name

First

Middle

Last

Date of Birth

Gender

Language:

Which of the following best describes the way your child

speaks most of the time?

No Words

Single Words (e.g., "juice," "bye bye," "more")

Phrases (e.g., "more juice please," "go swing outside")

Short Sentences (e.g., "I'm hungry mom," "I want to go swing outside")

Complex Sentences (e.g., "I had fun at school today because we got t watch a movie")

Motor:

Which of the following best describes how your child gets around?

Does not yet sit up alone

Crawling but not yet walking

Walking buy falls often

Walking and running well

Complex Sentences (e.g., "I had fun at school today because we got t watch a movie")

About Your Family

Parent/Caregiver 1

Name:

Relationship to patient:

Contact:

Street:

City

State

Zip Code

Parent/Caregiver 2

Name:

Relationship to patient:

Contact:

Street:

City

State

Zip Code

Is the child's legal guardian different than the caregiver(s) listed above?

Yes

No

Legal Guardian

Name:

Relationship to patient:

Reason for coming to clinic

My child needs an evaluation.

Yes

No

Please list any specific diagnoses that you have concerns about (e.g. Autism, ADHD, etc.)

My child already has a diagnosis or diagnoses but I need more information or a second opinion.

Yes

No

What diagnoses do you need more information about?

What questions do you have about the diagnosis?

I would like a second opinion

I need a medical confirmation of a diagnosis made by the school

I have questions about medicvations or medical problems

Other

Yes

No

Details

I (or my doctor) have concerns about my child's:

Development

Gross motor skills (running, jumping, balance)

Fine motor skills (writing, using forks/spoons)

Cognitive skills (thinking, intelligence, memory

Self-Care skills (toileting, showering, brushing teeth)

Learning (school grades, reading, writing, math)

Speech/language (late talking, hard to understand)

Behavior/Other

About your child's health

Primary Care Doctor

Birth History

Hospital:

Pregnancy:

Weeks:

Full-term

Early

Did you or your child experience complications during the pregnancy, delivery, or hospital stay?

Current Medical Information

Current Medications:

Current Medical Diagnoses:

Allergies:

Hearing

Hearing was tested - no concerns

Hearing was tested - problems reported

Hearing has not been tested

Known hearing impairment (e.g., deafness)

Other (specify details below)

Vision

Vision was tested - no concerns

Prescribed glasses - wears them regularly

Prescribed glasses - does not wear them

Not tested - but have concerns

Other (specify details below)

Additional Medical Information

Appointment Information

Will you need an interpreter?

Yes

No

Preferred Language:

The following individual(s) may also bring my child to their appointments

Please be aware that the person bringing the patient to the appointment should be able to answer questions about the patient's development, medical, and school history. This person may also receive the results of evaluations that are performed during the visit.

Name:

Relationship to patient:

Name:

Relationship to patient:

Name:

Relationship to patient:

Insurance Information

Insurance Name:

Policy Number:

Group Number:

Primary Insured

Name:

DOB:

Relationship to patient:

Street:

City

State

Zip Code

Request for records

MAPS Integrated Wellness

Medical Records Requested from Outside Treating Providers

(Please Print)

Patient Name: _
Date of Birth: _

Patient Mailing Address

Street:

City

State

Zip Code

Phone Number:

Is there another name that the patient's record may be under?

Other Name:

By signing below, I give my permission to request my/my child's medical records from the providers listed on the following page. These records will be used by the MAPS Integrated Wellness for evaluation and treatment purposes. Signing this form does not indicate my approval to release records from my child's/my MAPS Integrated Wellness records to the organizations outlined on this form.

I understand that I may revoke this Authorization at any time by notifying the entity privacy coordinator in writing, but if I do, it will not be effective for disclosures made prior to my revocation in reliance on the Authorization.
I understand potential for the information disclosed according to the authorization to be redisclosed by the recipient and no longer protected by the authorization.
I understand that MAPS Integrated Wellness may not condition the provision of treatment, payment, and enrollment in a health plan, or elegibility for benefits on signing this Authorization, except under the following circumstances:

Participation in research projects can be conditioned on my signing an Authorization to use and disclose PHI in the research.
Initial enrollment in health plans can be conditioned on signing an Authorization for the health plan to review PHI to make eligibility determinations.
Furnishing healthcare services to me at the request of a third party can be conditioned on me signing an Authorization for disclosure of PHI to the third party requesting the treatment.

This release expires within one year of the date signed or upon completion of evaluation/treatment services, whichever occurs first.

Signature of patient or personal representative:

Print name of patient:

____________________

Print name of personal
representative:

____________________

Relationship to patient:

Date:

Place of Birth

Name:

Address:

Phone/Fax#:

Date(s) Seen:

Pediatrician

Name:

Address:

Phone/Fax#:

Date(s) Seen:

School

Name:

Address:

Phone/Fax#:

Date(s) Seen:

IEP Document

Eligibility Report

Appointment Request Form

Thank you for contacting MAPS Integrated Wellness division of Developmental-Behavioral Pediatrics! Please complete the following form to request an evaluation through our clinic. Thank you!

Who is completing this form?

Name:

Relationship to patient:

About Your Child

Child's Name

First

Middle

Last

Date of Birth

Gender

Language:

Motor:

About Your Family

Parent/Caregiver 1

Name:

Relationship to patient:

Contact:

Street:

City

State

Zip Code

Parent/Caregiver 2

Name:

Relationship to patient:

Contact:

Street:

City

State

Zip Code

Is the child's legal guardian different than the caregiver(s) listed above?

Legal Guardian

Name:

Relationship to patient:

Reason for coming to clinic

My child needs an evaluation.

Please list any specific diagnoses that you have concerns about (e.g. Autism, ADHD, etc.)

My child already has a diagnosis or diagnoses but I need more information or a second opinion.

What diagnoses do you need more information about?

Details

My child's doctor has concerns about my child but I am unsure

About your child's health

Primary Care Doctor

Birth History

Hospital:

Pregnancy:

Weeks:

Did you or your child experience complications during the pregnancy, delivery, or hospital stay?

Current Medical Information

Current Medications:

Current Medical Diagnoses:

Allergies:

Additional Medical Information

Appointment Information

Will you need an interpreter?

Preferred Language:

The following individual(s) may also bring my child to their appointments

Please be aware that the person bringing the patient to the appointment should be able to answer questions about the patient's development, medical, and school history. This person may also receive the results of evaluations that are performed during the visit.

Name:

Relationship to patient:

Name:

Relationship to patient:

Name:

Relationship to patient:

Insurance Information

Insurance Name:

Policy Number:

Group Number:

Primary Insured

Name:

DOB:

Relationship to patient:

Street:

City

State

Zip Code

Request for records

(Please Print)

Patient Name: _____________________________ Date of Birth: _____________________________

Patient Name: _
Date of Birth: _

Print name of personal
representative: