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It's time to take a closer look ...

If you've been observing behavior or seeing symptoms that concern you, then it's time to check in with us. We've included several forms below that will help us to evaluate what's happening with your child. Just print off the form that applies and take time to complete it. Then, make an appointment and bring the form with you so we can sit down together to discuss your concerns and make a plan to deal with the situation.

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Online Diagnostic System - Chadis.com

Here is a link to Chadis.com, which is a web-based screening, diagnostic and management system that administers and analyzes pre-visit, online questionnaires completed by parents, teens or teachers and provides clinicians with instant access to valuable clinical data and resources. This is available to all of our patients. Contact us for our private access code. You can use Chadis to screen for developmental, behavioral, and mental health concerns.

Well-Child Visit Check-List

Print and fill out this Well-Child Visit Check-List PDF (343 Kb), then bring with you to each well-child visit. Not all questions may pertain to your child.

Depression Evaluation

If you are concerned that your child may be depressed, let’s talk. He/she may be spending more time alone, or not doing well in school. Please print and fill out the appropriate form(s):

Parent of a Male Teenager

Parent of a Female Teenager

Teenager (Male or Female)

Adult Evaluation Form

Anxiety Evaluation

Children experience anxious feelings, but if you think that your child is having a hard time adjusting to new situations, or is having trouble under pressure they may need support and we would like to help. Please print and fill out the appropriate evaluation form(s), then bring to the office if you are concerned:

Evaluation Form for a Child

Evaluation Form for the Parent

Evaluation Form for an older child or adult

Autism Screening

The American Academy of Pediatrics now recommends screening of all children for Autism at ages 18-months and 2 years of age. Prior to these visits, please print and fill out this Autism Screening Form PDF (11.73 Kb), then bring with you to our office.

Post-Partum Depression Evaluation

We are acutely aware that many of our mothers are having a hard time after having a baby. Please print and fill out this Post-Partum Depression Evaluation PDF (65.58 Kb), then bring to our office if you are worried.

Attention Deficit/Hyperactivity

Many of our patients have symptoms of Attention Deficit Disorder, Hyperactivity Disorder, or a combination of both. Therapies such as behavioral management and/or an addition of a medication will be appropriate. It is important to perform an evaluation to make sure that we have diagnosed our patients accurately and thus are able to treat them appropriately.

Please keep in mind that:
  • We need a form from a parent who lives with your child as well as forms filled out by each of the teachers who may best know your child.
  • We would like these forms prior to seeing your child in our office so that we have time to evaluate the forms and your child's chart.
  • Not all children need to be on medication.
Please download, print out, then mail the following first time evaluation forms:
After being diagnosed with ADD or ADHD

It is important to re-evaluate our treatment modalities; whether it is behavioral, medication, or a combination of both. Please download, print out, and mail the following forms. We need a form from a parent who lives with your child as well as forms filled out by each of the teachers who may best know your child. We would like these forms prior to seeing your child in our office so that we have time to evaluate the forms and your child's chart.

Please download, print out, then mail the following follow-up forms:
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Contact us today to find out more about our practice!

Address: 809 E. Ridge Road, Rochester, NY 14621  |  Phone: 585-266-0310  |  Fax: 585-266-9207

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