Evaluation Form (Under Age 18)

Visit Information
I am coming to Providence Behavioral Health for:*

Neuropsychological EvaluationPsychological EvaluationOther
Appointment Information*

I do not have an appointment yet.I do not have an appointment but I would like to be seen by a specific clinician.I have an appointment with a clinician.
Name and/or Appt Info
Why are you seeking evaluation services?*
Have you previously had an evaluation?

YesNo
If yes, what is the name of the doctor that performed the evaluation?
*Please bring a copy of any previous evaluation reports to the first appointment.
Referred for Evaluation by:

Financial Information
Insurance*

Please bill my insurance for services.**Please bill my primary insurance and secondary insurance.**I do not have insurance. I will pay out of pocket.
Primary Insurance
Insurance Provider
Policy Holder's Member ID Number
Policy Holder's Name on Card
Policy Holder's Relationship to Patient
Policy Holder's Date of Birth

MonthDayYear
Group Number/Employer
Policy Holder's Social Security Number
Patient's MA# or State ID (if applicable)
Behavioral/Mental Health or Provider Services (phone number)

Area CodePhone Number
Secondary Insurance
Secondary Insurance Provider
Insured's Name
Group Number/Employer
Patient's Member ID Number
Insured's Date of Birth

MonthDayYear
Insured's Social Security Number
Patient's MA# or State ID (if applicable)
Behavioral/Mental Health or Provider Services (phone number)

Area CodePhone Number
Front of Secondary Insurance Card

Upload a File

Cancelof
Back of Secondary Insurance Card

Upload a File

Cancelof
** Our office will contact your insurance provider(s) regarding coverage of services, copay, coinsurance, and/or deductible amount(s). You may be required to pay for costs not covered by our insurance provider(s). In order to know in advance what your cost will be, you should contact the Customer Service Department of your insurance provider(s) using the phone number on the back of your insurance card(s).

Developmental History

Motor
Age in months when child crawled.
Age in months when child sat alone.
Age in months when child stood alone.
Age in months when child walked alone.
Child was awkward or had slow motor skills compared to siblings/friends (e.g., running, skipping, climbing, etc.).

YesNo
Does the child have a history of using the opposite hand?

YesNo
Which hand does the child use most?

LeftRightBoth
Is there a family history of left-handed members?

YesNo

Signature and Submission
Please type your name below to indicate consent to treatment.
Patient's Signature

Clear
Write your signature by holding down your cursor along the line.
Date

MonthDayYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Parent/Guardian Signature

Clear
Write your signature by holding down your cursor along the line.
Date

MonthDayYear
Enter the message as it's shown*
Should be Empty:

Evaluation Questionnaire