DEVELOPMENTAL-BEHAVIORAL PEDIATRICS 8402 Harcourt Road, Suite 105 , IN 46260 317-582-8290 Phone 317-582-8291 Fax stvincent.org | ascension.org

Welcome to Developmental-Behavioral Pediatrics, Please arrive 15 minutes prior to your scheduled appointment in order to complete the registration process. Being late for your appointment might mean we will need to reschedule your appointment.

Your appointment is a Consultative Visit to become acquainted and for us to determine how your child's needs may best be met.

Enclosed you will find a Patient Information Packet which we ask you to review as soon as possible. This packet contains registration material, directions to our office, patient history forms and forms that must be completed by your child's school.

It is very important that you return the forms to our office prior to your appointment or bring to the office the day of the appointment. Having this information will allow us to address your concerns and provide recommendations in a more complete and efficient manner.

Please bring the following items with you to this appointment:

• Completed Patient Information Packet

• Insurance cards

• Driver's license or ID of parent/guardian

• Any other past medical, mental health, therapy, testing and school information pertaining to this appointment which you believe would be helpful

Please know that it is required by law that all children under the age of 18 be present with a legal guardian.

The appointment is scheduled to last 60-90 minutes. If you need to cancel or reschedule your appointment, please call our office at least 24 hours in advance so we may offer this time to another family.

We look forward to meeting you and your child. Please contact us if you have any questions.

Sincerely,

Developmental-Behavioral Pediatrics

Enclosures

11/2017

Patient Demographic Information Form Please fill out every space. If it does not pertain to you, please write N/A, for Not Applicable.

Patient Information Patient’s Name (Last, First, Middle) (Suffix) (Preferred) (Former Last Name)

If patient is a minor, list names/contact info of Parents (step)/Guardians (Last, First, Middle Initial) (Address) (Phone) (Relationship) ______Sex Date of Birth Social Security # Marital Status: ❑ Married ❑ Single ❑ Divorced ❑ Male ❑ Female ❑ Widowed ❑ Separated ❑ Partner Address City State Zip code

Home Phone Mobile Phone Work Phone

Patient Email

Preferred Languag e Race Ethnicity ❑ Hispanic ❑ Non-Hispanic Provider Information Primary Care Physician / Phone Number Referring Provider / Phone Number

Communication ❑ I authorize St.Vincent, and those parties acting on behalf of St.Vincent, to contact me about appointments and reminders for health services via: ❑ Home Phone ❑ Mobile Phone ❑ Email Is it OK to leave medical information on your answering machine or voice mail? ❑ Yes ❑ No

Patient Photos – (Photos may or may not be part of your patient care)

I _____DO or _____DO NOT give consent for photos to be taken of me for identification and/or treatment purposes. _____(Patient/Parent/Guardian Initials)

Emergency Contact Information Name Relationship

Home Phone # Mobile Phone #

Employment Employer’s name Phone

Address City State Zip code

Guarantor (Name to Whom Statements are Sent) Patient’s Relationship to G uarantor

Name (Last, First, Middle, Suffix) Date of Birth

Address City State Zip code

Employer Social Security #

Insurance Primary Insurance Company Subscriber’s Name (Policyholder)

Subscriber’s DOB Subscriber‘s Social Security # Relationship to Subscriber

Secondary Insurance Company Subscriber’s Name (Policyholder)

Subscriber’s DOB Subscriber’s Social Security # Relationship to Subscriber

Clinical Information Preferred Pharmacy

Preferred Lab

Financial and Treatment Consent By signing my name below: • I hereby guarantee payment in full within thirty (30) days of all charges established by St.Vincent Health for services rendered to me or my dependent, unless other arrangements satisfactory to St.Vincent Health have been made. This includes any charges that a third-party payer may determine to exceed usual and customary limits. • I understand and acknowledge that if any unpaid amounts owed by me are assigned to a third party for collection, I will be responsible for paying attorney fees, interest, court costs, and other costs of collection, including but not limited to collection agency fees. • I authorize Medicare, Medicaid, all relevant commercial payers to pay St.Vincent Health on my behalf for any services furnished to me or my dependent. I certify that I have read this assignment of benefits, that the information given by me is correct, and that I agree to all of the provisions contained in it. • I understand that if I am facing financial difficulty I can apply for financial assistance from St.Vincent Health. • The insurance information I have provided is current and correct. If I sign this form and the insurance card is found later to be outdated or invalid, I understand that I am responsible for paying for the services in full and will need to file with the insurance carrier myself. • I hereby consent to treatment by my St.Vincent Health Provider(s). I understand that St.Vincent Health will release to my referring or subsequent healthcare provider, reports of my medical condition that will assist him or her in my continuing care and as needed to process claims and for general health care operations. I agree that this Consent is valid for all treatment and payment of said treatment for a period of twelve (12) months following execution of the Consent. • I understand my insurance co-pay is due at the time of service, per my insurance company policy.

I ACKNOWLEDGE RECEIPT OF THE NOTICE OF PRIVACY PRACTICES :______(Patient’s Initials)

Patient/Guarantor/Guardian Signature Date

**OFFICE USE ONLY** NPP Witness/Issued by: ______

Developmental -Be h a v i o r a l Pe d i a t r i c s

History form

8402 Harcourt Road, Suite 105 Indianapolis, IN 46260

Tel: (317) 582-8290 • Fax: (317) 582-8291

Child’s Name ______Birth Date ______Child’s Nickname ______

Please feel free to use the backs of these pages to further explain answers, if needed.

I. PURPOSE OF EVALUATION

What are your questions or concerns regarding your child?

II. PREGNANCY AND BIRTH HISTORY

This section is to be completed by the mother of the child, if possible. Please indicate if answered by another person: ______.

Number of pregnancies you have had ______Number of live births ______Number of stillbirths ______Number of miscarriages ______Number of living children ______Number of deceased children ______This child was the product of pregnancy number ______Page 2 Child’s Name ______

Yes No Do Not Know Comments Did you have any health problems during pregnancy with this child? If yes, please describe the problem and the time it oc- curred during the pregnancy (such as infections, high blood pressure, diabetes, bleeding, weight loss, accidents, fever, etc.)

Did you take any medication, smoke, drink, or use drugs during this pregnancy? If yes, please list. Was your baby carried a full nine months? If no, please indi- cate length of the pregnancy. Were there any difficulties with delivery? If yes, please de- scribe the problems (such as Cesarean section, slow heart rate, fever, etc.)

How much did your baby weigh at birth? ______pounds, ______ounces

Did your baby need any special care during the first few days after delivery? If yes, please describe.

Did you have any difficulty caring for your child during the first few months of life? If yes, please describe.

III. PAST AND PRESENT HEALTH HISTORY

Yes No Do Not Know Comments Has your child ever been hospitalized? If yes, please de- scribe, including child’s age. Has your child ever had any serious accidents requir- ing medical care? If yes, please describe, including your child’s age.

Does your child have any serious or chronic illnesses? Please describe.

Has your child ever had a seizure or convulsion? If yes, please describe, including child’s age.

Has your child ever had tics? (Facial movements, eye- blinking, vocalizations, etc.)

Has your child ever had heart problems? If yes, please describe. Page 3 Child’s Name ______

Yes No Do Not Know Comments Is your child presently taking any medication, herbals, or vitamins? If yes, please list the medications, dosages, and why. Does your child have any known allergies? Please de- scribe. Do you feel your child has trouble hearing? If yes, please explain. Do you feel your child has trouble seeing? If yes, please explain. Has your child been or is your child now on a special diet? If yes, please describe.

IV. DEVELOPMENTAL HISTORY

Yes No Do Not Know Comments Was your child’s development any faster or slower than that of other children? Please explain. At what age did your child sit alone? At what age did your child crawl? At what age did your child walk alone? At what age did your child make sounds? At what age did your child say single words? At what age did your child combine words? Is your child toilet trained? If yes, age what age? Does your child have toileting accidents during the day? If yes, how often? Does your child have toileting accidents during the night? If yes, how often? Page 4 Child’s Name ______

Please describe what toys or activities your child enjoys:

Describe your child’s interactions with family members and other children:

Please describe what your consider to be your child’s strengths:

Has your child received or been evaluated for any of the following?

Yes No Date Educational Psychological Testing Speech/language therapy Physical therapy Occupational therapy Tutoring Individualized and/or Family Counseling Other (please list)

V. EDUCATIONAL/SOCIAL HISTORY

Please list the schools your child has attended:

Name Dates Attended

Preschool: ______Elementary: ______Middle School:______High School: ______

If you work outside your home, who provides care for your child while you are at work?

Please list extracurricular activities in which your child has participated: Page 5 Child’s Name ______

Please describe your child’s study habits:

Please describe your child’s present peer group.

Do you have concerns regarding possible alcohol and/or drug use? ___ Yes ___ No If yes, please explain.

VI. CHILD’S BEHAVIOR

***PLEASE COMPLETE THE VANDERBILT PARENT ASSESSMENT SCALE

Yes No Do Not Know Comments Does your child have any unusual fears? If yes, please explain. Do you have any concerns about the management of your child’s behavior at home (e.g., sleeping, tantrums, entertaining him/herself)? If yes, please explain.

VII. FAMILY HISTORY

Parents are:

Date Married ______Separated ______Divorced* ______*If parents are divorced, please describe current custody and Unmarried ______visitation arrangements: ______Widowed ______

Is your child a foster child? _____ Yes _____ No Length of time in your home ______

Is child adopted? _____ Yes _____ No Age at adoption ______

If a foster child or adopted, has this been discussed with your child? _____ Yes _____ No Who has legal guardianship of the child? ______Page 6 Child’s Name ______

Please list the persons presently living in your home: Name Sex Birth Date Relation to Child Present or Highest Grade Completed

Family members no longer in home: Name Sex Birth Date Relation to Child Present or Highest Grade Completed

During the past 12 months, has your family experienced any of the following difficulties? Yes No Do Not Know Comments Death of a family member Serious illness Marital problems Unemployment Other (please describe)

Have any other family members had any of the following? Yes No Do Not Know Comments Heart or blood pressure problems? If yes, please describe. Other medical problems? If yes, please describe. Tic, learning, developmental, or attention- deficit problems? If so, please describe.

Person completing questionnaire ______

Relationship to Child ______

Date ______NICHQ Vanderbilt Assessment Scale—PARENT Informant

To day’s Date: ______Child’s Name: ______Date of Birth: ______Parent’s Name: ______Parent’s Phone Number: ______

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months. Is this evaluation based on a time when the child was on medication was not on medication not sure?

Symptoms Never Occasionally Often Very Often 1. Does not pay attention to details or makes careless mistakes 0 1 2 3 with, for example, homework 2. Has difficulty keeping attention to what needs to be done 0 1 2 3 3. Does not seem to listen when spoken to directly 0 1 2 3 4. Does not follow through when given directions and fails to finish activities 0 1 2 3 (not due to refusal or failure to understand) 5. Has difficulty organizing tasks and activities 0 1 2 3 6. Avoids, dislikes, or does not want to start tasks that require ongoing 0 1 2 3 mental effort 7. Loses things necessary for tasks or activities (toys, assignments, pencils, 0 1 2 3 or books) 8. Is easily distracted by noises or other stimuli 0 1 2 3 9. Is forgetful in daily activities 0 1 2 3 10. Fidgets with hands or feet or squirms in seat 0 1 2 3 11. Leaves seat when remaining seated is expected 0 1 2 3 12. Runs about or climbs too much when remaining seated is expected 0 1 2 3 13. Has difficulty playing or beginning quiet play activities 0 1 2 3 14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3 15. Talks too much 0 1 2 3 16. Blurts out answers before questions have been completed 0 1 2 3 17. Has difficulty waiting his or her turn 0 1 2 3 18. Interrupts or intrudes in on others’ conversations and/or activities 0 1 2 3 19. Argues with adults 0 1 2 3 20. Loses temper 0 1 2 3 21. Actively defies or refuses to go along with adults’ requests or rules 0 1 2 3 22. Deliberately annoys people 0 1 2 3 23. Blames others for his or her mistakes or misbehaviors 0 1 2 3 24. Is touchy or easily annoyed by others 0 1 2 3 25. Is angry or resentful 0 1 2 3 26. Is spiteful and wants to get even 0 1 2 3 27. Bullies, threatens, or intimidates others 0 1 2 3 28. Starts physical fights 0 1 2 3 29. Lies to get out of trouble or to avoid obligations (ie,“cons” others) 0 1 2 3 30. Is truant from school (skips school) without permission 0 1 2 3 31. Is physically cruel to people 0 1 2 3 32. Has stolen things that have value0123

The information contained in this publication should not be used as a substitute for the Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s medical care and advice of your pediatrician. There may be variations in treatment that Healthcare Quality your pediatrician may recommend based on individual facts and circumstances. Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised - 1102 NICHQ Vanderbilt Assessment Scale—PARENT Informant

To day’s Date: ______Child’s Name: ______Date of Birth: ______Parent’s Name: ______Parent’s Phone Number: ______

Symptoms (continued) Never Occasionally Often Very Often 33. Deliberately destroys others’ property 0 1 2 3 34. Has used a weapon that can cause serious harm (bat, knife, brick, gun) 0 1 2 3 35. Is physically cruel to animals 0 1 2 3 36. Has deliberately set fires to cause damage 0 1 2 3 37. Has broken into someone else’s home, business, or car 0 1 2 3 38. Has stayed out at night without permission 0 1 2 3 39. Has run away from home overnight 0 1 2 3 40. Has forced someone into sexual activity 0 1 2 3 41. Is fearful, anxious, or worried 0 1 2 3 42. Is afraid to try new things for fear of making mistakes 0 1 2 3 43. Feels worthless or inferior 0 1 2 3 44. Blames self for problems, feels guilty 0 1 2 3 45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her” 0 1 2 3 46. Is sad, unhappy, or depressed 0 1 2 3 47. Is self-conscious or easily embarrassed 0 1 2 3 Somewhat Above of a Performance Excellent Average Average Problem Problematic 48. Overall school performance1 2 3 4 5 49. Reading 1 2 3 4 5 50. Writing 1 2 3 4 5 51. Mathematics 1 2 3 4 5 52. Relationship with parents1 2 3 4 5 53. Relationship with siblings 1 2 3 4 5 54. Relationship with peers 1 2 3 4 5 55. Participation in organized activities (eg, teams) 1 2 3 4 5 Comments:

For Office Use Only Total number of questions scored 2 or 3 in questions 1–9: ______Total number of questions scored 2 or 3 in questions 10–18:______Total Symptom Score for questions 1–18: ______Total number of questions scored 2 or 3 in questions 19–26:______Total number of questions scored 2 or 3 in questions 27–40:______Total number of questions scored 2 or 3 in questions 41–47:______Tot a l numb er of questions scored 4 or 5 in questions 48–55: ______Average Performance Score: ______D4 NICHQ Vanderbilt Assessment Scale—TEACHER Informant

Teacher’s Name: ______Class Time: ______Class Name/Period: ______Today’s Date: ______Child’s Name: ______Grade Level: ______

Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors: ______. Is this evaluation based on a time when the child was on medication was not on medication not sure? Symptoms Never Occasionally Often Very Often 1. Fails to give attention to details or makes careless mistakes in schoolwork 0 1 2 3 2. Has difficulty sustaining attention to tasks or activities 0 1 2 3 3. Does not seem to listen when spoken to directly 0 1 2 3 4. Does not follow through on instructions and fails to finish schoolwork 0 1 2 3 (not due to oppositional behavior or failure to understand) 5. Has difficulty organizing tasks and activities 0 1 2 3 6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained 0 1 2 3 mental effort 7. Loses things necessary for tasks or activities (school assignments, 0 1 2 3 pencils, or books) 8. Is easily distracted by extraneous stimuli 0 1 2 3 9. Is forgetful in daily activities 0 1 2 3 10. Fidgets with hands or feet or squirms in seat 0 1 2 3 11. Leaves seat in classroom or in other situations in which remaining 0 1 2 3 seated is expected 12. Runs about or climbs excessively in situations in which remaining 0 1 2 3 seated is expected 13. Has difficulty playing or engaging in leisure activities quietly 0 1 2 3 14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3 15. Talks excessively 0 1 2 3 16. Blurts out answers before questions have been completed 0 1 2 3 17. Has difficulty waiting in line 0 1 2 3 18. Interrupts or intrudes on others (eg, butts into conversations/games) 0 1 2 3 19. Loses temper 0 1 2 3 20. Actively defies or refuses to comply with adult’s requests or rules 0 1 2 3 21. Is angry or resentful 0 1 2 3 22. Is spiteful and vindictive 0 1 2 3 23. Bullies, threatens, or intimidates others 0 1 2 3 24. Initiates physical fights 0 1 2 3 25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others) 0 1 2 3 26. Is physically cruel to people 0 1 2 3 27. Has stolen items of nontrivial value 0 1 2 3 28. Deliberately destroys others’ property 0 1 2 3 29. Is fearful, anxious, or worried 0 1 2 3 30. Is self-conscious or easily embarrassed 0 1 2 3 31. Is afraid to try new things for fear of making mistakes 0 1 2 3

The recommendations in this publication do not indicate an exclusive course of treatment Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s or serve as a standard of medical care. Variations, taking into account individual circum- Healthcare Quality stances, may be appropriate. Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised - 0303

HE0351 D4 NICHQ Vanderbilt Assessment Scale—TEACHER Informant, continued

Teacher’s Name: ______Class Time: ______Class Name/Period: ______Today’s Date: ______Child’s Name: ______Grade Level: ______

Symptoms (continued) Never Occasionally Often Very Often 32. Feels worthless or inferior 0 1 2 3 33. Blames self for problems; feels guilty 0 1 2 3 34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her” 0 1 2 3 35. Is sad, unhappy, or depressed 0 1 2 3 Somewhat Performance Above of a Academic Performance Excellent Average Average Problem Problematic 36. Reading 1 2 3 4 5 37. Mathematics 1 2 3 4 5 38. Written expression 1 2 3 4 5 Somewhat Above of a Classroom Behavioral Performance Excellent Average Average Problem Problematic 39. Relationship with peers 1 2 3 4 5 40. Following directions 1 2 3 4 5 41. Disrupting class 1 2 3 4 5 42. Assignment completion 1 2 3 4 5 43. Organizational skills 1 2 3 4 5 Comments:

Please return this form to: ______

Mailing address: ______

______

Fax number: ______

For Office Use Only Total number of questions scored 2 or 3 in questions 1–9: ______Total number of questions scored 2 or 3 in questions 10–18: ______Total Symptom Score for questions 1–18: ______Total number of questions scored 2 or 3 in questions 19–28: ______Total number of questions scored 2 or 3 in questions 29–35: ______Total number of questions scored 4 or 5 in questions 36–43: ______Average Performance Score:______

11-20/rev0303 Developmental -Be h a v i o r a l Pe d i a t r i c s

TEACHER INFORMATION REQUEST

8402 Harcourt Road, Suite 105 Indianapolis, IN 46260 Tel: 317-582-8290 ● Fax: 317-582-8291

Patient Name:______DOB: ______will see a developmental-behavioral pediatrician. In order to provide a comprehensive picture of his/her abilities, we request that you complete the information below. The completed form may be returned to the patient and/or directly to our office via the contact information above. We appreciate your time and assistance.

1. What is your relationship to the student? How long have you known him/her? ______

2. Please give a brief description of the student’s school program including setting, type of classroom, and any special services such as tutoring, resource support, speech/language therapy, counseling, etc. ______

3. Please describe the student’s developmental, adaptive, and/or academic performance. Include the results of any standardized test scores or annual reports. ______

4. Has this student had any developmental, special education, or psychological testing? If so, please include the results of these tests. ______

5. Please describe the student’s behavior, including mood, response to assignments, ability to concentrate, and peer/authority relationships. ______Developmental -Be h a v i o r a l Pe d i a t r i c s

TEACHER INFORMATION REQUEST

6. On the basis of your experience with other students this age/grade, do you feel this child is working up to his/her academic potential? ______

7. Do you have any other specific questions, concerns or additional information about this student that you feel would be particularly helpful in our evaluation? ______

______Teacher’s Name (Please print) Course or grade Date From Northwest of Indianapolis Take South to Interstate 865 to Interstate 465 East. Continue on Interstate 465 East to the /US421 exit (Exit 27). Turn right and head south to 86th Street. Turn left on 86th Street and head east. Turn right onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St. Vincent Hospital on Harcourt Road.

From Northeast of Indianapolis Take South to Interstate 465 West. Continue on Interstate 465 West to the Meridian Street/US31 exit (Exit 31). Turn left and head south to 86th Street. Turn right on 86th Street and head west. Turn left onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St. Vincent Hospital on Harcourt Road.

From East of Indianapolis Take West or West to Interstate 465 North. Continue on Interstate 465 North, which turns into Interstate 465 West. Continue on Interstate 465 West to the Meridian Street/US31 exit (Exit 31). Turn left and head south to 86th Street. Turn right on 86th Street and head west. Turn left onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St. Vincent Hospital on Harcourt Road.

From South of Indianapolis Take Interstate 65 North to Interstate 465 West. Continue on Interstate 465 West, which turns into Interstate 465 North. Continue on Interstate 465 North, which turns into Interstate 465 East. Continue on Interstate 465 East to the Michigan Road/US421 exit (Exit 27). Turn right and head south to 86th Street. Turn left on 86th Street and head east. Turn right onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St. Vincent Hospital on Harcourt Road.

From West of Indianapolis Take Interstate 70 East or Interstate 74 East to Interstate 465 North. Continue on Interstate 465 North, which turns into Interstate 465 East. Continue on Interstate 465 East to the Michigan Road/US421 exit (Exit 27). Turn right and head south to 86th Street. Turn left on 86th and head east. Turn right onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St. Vincent Hospital on Harcourt Road.

Where to Park Free parking is available at Peyton Manning Children’s Hospital at St. Vincent and at the Indianapolis Hospital main parking lot on 86th Street between Harcourt Road and Naab Road. Parking is available for a nominal fee at the garage adjacent to the Professional Office building, 8402 Harcourt Road. Free parking is available at all other campus locations.

8402 Harcourt Road • Indianapolis, IN 46260 317-338-KIDS (5437) • stvincent.org/peytonmanning

© St. Vincent 505118