Orange County Child Neurology

FORMS REQUESTED PRIOR TO YOUR INITIAL VISIT

We request paperwork prior to SCHEDULING your first visit.

Please send in the following via fax (949) 354-0612 or email to occhildneuro@gmail.com

Fill out all forms in BLACK ink ONLY.

Insurance Card (Front/Back)

Parent Questionnaire

Demographics Information

Protected Health Information Consent

Financial Agreement

Medication Policy

ADHD Evaluations: Children Under <12 & Patients >12 and Older

Children younger than 12: Our practice offers ADHD evaluations. Please contact our office to schedule an appointment.

Patients age 12 and older: Before establishing a new ADHD diagnosis, our practice recommends a comprehensive evaluation by a neuropsychologist to clarify attention, learning, and behavioral needs. Please contact our office for a list of neuropsychology providers.

Once a diagnosis has been established, we are happy to discuss treatment options, including medication management when appropriate.

Additional Forms for ADHD/ADD Evaluation:

Parent Vanderbilt Form

Teacher Vanderbilt Form

Additional Forms for Migraine/Headache Evaluation:

Headache Diary

Additional Forms for Concussion Evaluation:

ImPACT Testing Form

To send outside records to our office, please complete a Release of Records form.

Record Release Authorization

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