Patient Forms

Individual Patient Forms

Release of Information

ADHD Assessment Forms

Vanderbilt Parent Initial Assessment

Vanderbilt Parent Follow-up

Vanderbilt Teacher Initial Assessment

Vanderbilt Teacher Follow-up

Screening Tools for Anxiety and OCD

SCARED Anxiety Survey – Child Form

SCARED Anxiety Survey – Parent Form

CY-BOCS OCD Symptom Checklist

Patient registration form

Care provider form

ROI form

General operational policies and procedures form

Receipt of privacy practices form

Financial policy form

Notice of privacy practices form

Credit card policy form

Vanderbilt Assessment Forms

Vanderbilt
Parent Initial Assessment

Vanderbilt
Parent follow-up

Vanderbilt
Teacher Initial Assessment

Vanderbilt
Teacher follow-up

Screen for Child Anxiety Related Disorders

To be filled out by Child

To be filled out by Parent

Insurance Billing
We are not in network with any insurance companies, and payment is due in full at the time of service. We provide a Superbill (a detailed receipt) that can be submitted to insurance for reimbursement and are happy to provide assistance with that process if needed. Here are some links to reimbursement forms/procedures for some of the more common insurance plans:

Aetna: Health Reimbursement Claim Form

Cigna: Reimbursement Medical Claim Form

Providence: Member Forms

Regence: Direct Member Reimbursement Form

United: Medical Claim Form

MODA: Claim Forms