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Forms

 
Orange Blossom

Background Questionnaire

Please complete and return to me prior to the start of evaluation

Dry Woods

Release of Information

Parent consent is required to release any information or consult with other providers/professionals

Teacher and Young Student

Teacher Questionnaire

Please have your child's primary teacher complete this form and send it back to me

Blue Hummingbird

HIPAA Disclosure  Form

Contains information about the rules and restrictions around protected health information (PHI).

Pencils

HIPAA Waiver

This is a an acknowledgment of waiver of right to receive notice of HIPAA privacy policies.

Playful Kids

Consent to Communicate Information Electronically

This consent form will allow us to communicate information electronically.

Mountain Range

ALAS Disclosure Statement

This statement outlines ALAS' terms, conditions, risks and rules