Forms
PATIENTS CAN REGISTER ONLINE AT:
https://southerntierpeds.myezyaccess.com/Patient/Main.aspx
CCMH COUNSELING REGISTRATION FORMS:
CCMH New Counseling Registration Packet
GENERAL FORMS:
- Release-of-Records-Form-02062017
- Authorized Patient Contacts Form
- Notice Of Privacy Practice Disclosure
- Office Information, Financial Policy, and Patient Rights and Responsibilities
- Vaccine Policy
*****FORMS TO BRING TO APPOINTMENTS*****
Please print, complete, and bring these form(s) to your child’s appointment if your child is being seen for any of the following:
ADHD:
- ADHD Vanderbilt Form to be Completed by a Parent
- ADHD Vanderbilt Form to be Completed by a Parent in Spanish
- ADHD Vanderbilt Form to be Completed by a Teacher
- ADHD Vanderbilt Parent FOLLOW UP
- ADHD Vanderbilt Teacher FOLLOW UP
Aggression:
Anxiety:
- Anxiety Screening to be Completed by a Parent
- Anxiety Screening to be Completed by a Parent in Spanish
- Anxiety Screening to be Completed by a Child
- Anxiety Screening to be Completed by a Child in Spanish
Autism/Developmental Delays:
- Developmental Screening (Please note this form should be completed and brought to ALL 16-30 month Well Child Visits.)
Depression:
- Depression Screening for Teens (Please note this form should be completed and brought to ALL Well Child Visits starting at 12 years old and ALL appointments for Depression.)
- Depression Screening for Teens in Spanish
- Depression Screening Adults (Please note this form should be completed and brought to ALL 20 year old and over Well Visits and ALL appointments for Depression.)
- Depression Screening for Women Who Are Pregnant or Have Recently Given Birth (Please note this form should be completed and brought to ALL Well Baby Visits from Newborn – 1 month old.)
Drug/Alcohol Abuse Screening:
- Drug Abuse Screening
- Drug and Alcohol Abuse Screening (Please note this form should be completed and brought to ALL Well Child Visits starting at 12 years old.)
- Drug and Alcohol Screening in Spanish
Eating Attitude Test:
Obsessive Compulsive Behavior Screening:
PTSD