3205 Randall Parkway • Suite 117 Wilmington, North Carolina 28403 • (910) 332-4134


Forms

If you plan on coming in for an appointment, please download all of the appropriate forms, and fill them out in advance. Or, you can fill these forms out in person on the day of appointment. All except for Biographical Information and the Consent to Obtain Information From, and the two questionnaires are required by law.

Complete either or both of the questionnaires only if they are relevant to your situation.

   
  ADHD Questionnaire - for Parent(s) to answer
  ADHD Questionnaire - for Teacher(s) to answer
  Anxiety Questionnaire - for parents to complete on their child
  Anxiety & Depression Questionnaire
  Biographical History

Confidentiality
  Consent for Treatment of a Minor
  Consent to Obtain Information From
  Contact Information
  HIPAA Notice of Privacy Practices
  Informed Consent 
  Insurance and Financial Responsibility
   


Forms are in Adobe Acrobat format and may be viewed and printed using Adobe Acrobat Reader.
If you do not have Adobe Acrobat Reader, click on the icon below to download it.

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For more information contact Dr. Cahn

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