PATIENT POLICIES & FORMS
Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2, 4, or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.
Please click on the link below for the questionnaire to complete.
ASQ Questionnaire
ASQSE Form (or social emotional)
- New Patient Registration Form
- Financial Policy Form - Consent for Treatment.docxm
- Sliding Fee Application.docx
- Patient Privacy Information Notice
- Notice of Privacy Practices.doc
- Medical Records Release Form.pdf
- Intake Form (2-9 years)/IntakeForm.docx(10+) - the intake form must be completed each time you visit the clinic, or once every week if consecutive visits at the clinic have occurred.
- Mychartor.providence.org/mychart/ - Access your test results, manage your appointments, communicate with your doctor, refill prescriptions (by mail only).
Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2, 4, or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.
Please click on the link below for the questionnaire to complete.
ASQ Questionnaire
ASQSE Form (or social emotional)
