Child Evaluation

What Do I Bring to the Initial Evaluation?

To view the forms, simply click on the name of the file to open it (Adobe Acrobat Reader 4.0 or above required). You will then have the opportunity to print the file if desired.

Forms not submitted online should be printed, filled out, then sent via fax/mail, or presented at the time of your visit.

• Insurance Card
• Service Agreement Form (CLICK HERE)
• Prescription/ Physician’s Order Form for evaluation (CLICK HERE)
** IN ORDER TO DO AN EVALUATION, FAC NEEDS TO HAVE A PRESCRIPTION**

Registration Forms
Please print and complete the forms below and bring with you to your visit.
• Patient History Form Child (CLICK HERE)
• Patient Registration Form (CLICK HERE)
• Insurance Information Form (CLICK HERE)

• Hippa Notice of Privacy Practices (CLICK HERE)
• Authorization to Release Information (CLICK HERE)

PLEASE NOTE: If these forms are not filled out, please arrive 15 minutes early to your evaluation to fill out paperwork.

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