Associated Therapists, Inc.
Providing administrative support to a group of independent Mental Health private practitioners located in Southern California

Home Page Professional Staff Office Locations Contact Us

 
   

Forms and Questionnaires

Below are copies of forms, letters and questionnaires to assist in managing and reporting information regarding yourself or your child. These forms must first be printed, then mailed or brought to your school, therapist, nurse or doctor.

Click on the link below for the form that you are looking for. When the form appears, use your Internet browser print command and print a copy of the form. After the form prints, use your browser "Back" button or command to continue.
 
 

New Clients

 

Print Paper Form - Insurance
These forms will allow us to set up your account in our system. These forms are to be used by individuals with mental health insurance coverage.
Enter new client information online: Click Here

   
 

Print Paper Form - Cash
These forms will allow us to set up your account in our system. These forms are to be used by clients that DO NOT have insurance.
Enter new client information online: Click Here

   
 

Children And Teenagers

 

Child and Teen Symptom Check List
A rating scale developed by Dr. Amen to report symptoms a child or teen may be experiencing. Use this form on your first visit, if instructed.

   
  Weekly Mood Chart
  Parents track a child's moods and emotions throughout the day.
   
 

Amen Brain System Check List
A rating scale developed by Dr. Amen to report various symptoms such as anxiety, depression, anger, and attention difficulties.

   
 

Parent Assessment Scale
Vanderbilt ADHD Diagnostic Parent Rating Scale
A questionnaire for parents to report on child's behavior

   
 

Teacher Assessment Scale
Vanderbilt Assessment Scale –Teacher Informant
A questionnaire for teachers to report your child's behaviors in school.

   
 

Teacher Follow Up Assessment
For teachers to report the progress of your child.
Use this form if your child is on medication.

   
 

ADD-ADHD Medication Effects - Child
Questionnaire for adults to help report the effects of medication on a child with ADD-ADHD. Use this form if your child is on medication.

   
 

School Daily or Weekly Report
Daily or Weekly form for teachers to report behavior, academic and homework information. Use this form to help communicate with home and school.

   
 

Student Accommodations
A form requesting and listing specific accommodations for an ADD-ADHD child in a regular classroom.

   
 

Form Letters Requesting School Action
The following letters are samples you may use or modify to communicate with a school district. Reprinted from the book: "The Complete IEP Guide: How to Advocate for Your Special Ed Child"
by Lawrence M. Siegel. Recommended if you need special services from a school district.
Order from Amazon.com

   
 

Request for Accommodations Letter
A form letter requesting a school meeting for evaluation and determining appropriate accommodations for an ADD-ADHD child.

   
 

Request Child's School File
A form letter requesting a child's entire school file from a school district.

   
 

Requesting Special Education Information
A form letter requesting that a school district send you information regarding Special Education procedures.

   
 

Begin Evaluation of a Child
A form letter formally requesting that a school district begin the evaluation and testing of your child.

   
 

Adults

 

Adult ADD Screening Check List
Jasper / Goldberg Adult ADD Screening Examination - Version 5.0. A rating scale for adults who may experience ADD symptoms.

   
 

Amen Brain System Check List
A rating scale developed by Dr. Amen to report various symptoms such as anxiety, depression, anger, and attention difficulties. Use this form on your first visit, if instructed.

   
 

General Forms - All Clients

 

ADD-ADHD Medication Chart
View a comprehensive listing of the commonly used medications to treat ADHD in children and adults. Dosing information, main effects, adverse effects, and precautions are listed. Use this information only in collaboration with your physician.

   
 

Release of Confidential Information
A HIPAA compliant form that authorizes the release of your confidential information to a specific person for a specific reason for a specific length of time.

   
These paper forms use the Adobe Portable Document Format (PDF). You must have a copy of the Adobe Reader installed on your computer. If you do not have this program you may download a FREE copy by clicking the "Get Adobe Reader" button below.
 
Adobe Reader

Page Last Updated: 01/28/12