Forms

If someone else other than a parent/guardian will be bringing your child to an appointment.

• Authorization to Treat Form (one per child)

• Behavioral Intake Packet
• ADHD Parent Follow-Up Form
• ADHD Parent Initial Form
• ADHD Teacher Follow-Up Form
• ADHD Teacher Initial Form

For preschool, Head Start or other early education program.

• Health Appraisal Form

Upon turning 18 years old, you are a legal adult and must complete the following form:

• Eighteen and Older Patient Form

Our goal as pediatricians are to have our patients outgrow us. While we are happy to follow college students through that transitory time of life, once you 1) graduate from college and/or 2) begin living a more independent/adult lifestyle, it is time to begin the transition to an adult physician. 

In the event of a transfer out of our practice for any reason, it is suggested that you complete the following form so your next provider can take the best care of you possible:

• Records Release to Another Clinic Form

Sports Forms:

MHSAA Sports Form - for school sports grade 6 and above*

• High School Sports Physical Form (need form)

*Of note, the MHSAA requires these forms to be signed AFTER April 15 for the following school year sports. If your child has had a well visit prior to this date, he/she will need to come back to clinic for an exam to get the form signed per MHSAA regulations. 

School Medication Authorization Forms:

• TCAPS
• TBAISD
• Grand Traverse Academy
• Kingsley Area Schools
• Generic School Medication Form

• MCHAT
• SCARED Anxiety Screen (parents to complete)
• Edinburgh Postnatal Depression Scale
• GAD-7
• SCARED Anxiety Screen (child to complete)
• PSC-17
• PHQ-9 (Modified for Teens)
• PHQ-9 (Adult)

• Patient and Family Information Form
• Pediatric Medical History Form
• Records Release to TAPAC Form - please fill out A FORM FOR EACH CLINIC in which your child has been a patient
• HIPAA Authorization Form
• Exchange of Information/Permission to Discuss
• Financial Policy
• Authorization to Treat Form (If someone other than a parent/guardian will be bringing your child to an appointment at any time)