MENTAL HEALTH ASSESSMENTS

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1ENTER PATIENT INFORMATION

2COMPLETE PATIENT ASSESSMENTS

3SEND TEACHER ASSESSMENTS

Patient's Name*

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Patient's Date of Birth

Date of Birth*

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Calculated Age

Who is completing this form?*

What is your relationship to ?*

Has had any previous evaluations with a speech therapist, physical or occupational therapist, school psychologist, private psychologist and/or psychiatrist?*

Does currently have a 504 or IEP in place at school? (Your child has an IEP or 504 Plan if they receive special education services, such as participating in the Dyslexia program, receiving resource instruction, receiving speech, physical or occupational therapy services at school, and/or accommodations for any mental health or medical diagnoses.)*

Has been seen by a neurologist and/or had genetic testing?*

Please complete the assessments listed below.

Intake Questionnaire

Patient's Name	Actions

There are no Intake Questionnaire.

AQ-10 Assessment

AQ-10 (ages 4-11) Assessment Score	Actions

There are no AQ-10 Assessment.

AQ-10 Assessment

AQ-10 (ages 12-15) Assessment Score	Actions

There are no AQ-10 Assessment.

Mood & Feelings Assessment

Mood and Feelings Assessment Score	Actions

There are no Mood & Feelings Assessment.

SCAS Assessment

Panic Attack / Agoraphobia Score	Separation Anxiety Score	Physical Injury Fears Score	Social Phobia Score	Obsessive Compulsive Score	Generalized Anxiety / Overanxious Score	Total Score	Actions

There are no SCAS Assessment.

RCADS Assessment

RCADS Assessment Score	Actions

There are no RCADS Assessment.

SCARED Assessment

Total	Panic Disorder or Significant Somatic Symptoms	Generalized Anxiety Disorder	Separation Anxiety Disorder	Significant School Avoidance	Social Anxiety Disorder	Actions

There are no SCARED Assessment.

PAS Assessment

Total Score	Separation Anxiety Score	Physical Injury Fears Score	OCD Score	Social Anxiety Score	Generalized Anxiety Score	Actions

There are no PAS Assessment.

ASAS Assessment

Total Score	Actions

There are no ASAS Assessment.

Parent Vanderbilt Assessment

PREDOMINANTLY INATTENTIVE SUBTYPE SCORE	PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE	ADHD COMBINED INATTENTION / HYPERACTIVITY	OPPOSITIONAL-DEFIANT DISORDER SCREEN	CONDUCT DISORDER SCREEN	ANXIETY / DEPRESSION SCREEN	Actions

There are no Parent Vanderbilt Assessment.

Document Upload

Patient's Name	Actions

There are no Document Upload.