Patient Forms
Download Patient Forms
Complete only the forms requested by your Kids Health Alliance care team. English and Spanish downloads are shown where available. PDFs open in a new tab.
New Patient Forms
Patient Registration
Office Policy
New Patient History
Medical Records Consent
Notice of Privacy Practices
Summary of Privacy Rights
Established Patient Forms
Patient History Update
Behavioral & Mental Health Forms
Behavior History
Parent Vanderbilt — Initial Evaluation
Teacher Vanderbilt — Initial Evaluation
Depression & Anxiety (PHQ-9 and GAD-7)
ADHD/Mental Health Follow-Up
SCARED — Child & Parent
PHQ-9
Developmental Screening
EPDS — Postpartum Depression
PEDS — Developmental Concerns
M-CHAT
Sliding Fee Assistance & Application
Sliding Fee Application
Discounted care may be available based on household size and income. Bring your completed application, household information and proof of income, such as a tax return, W-2, recent pay stubs or benefit statements.
Solicitud de descuento según los ingresos
Puede haber descuentos según el tamaño y los ingresos del hogar. Traiga la solicitud completa, información sobre los miembros de su hogar y comprobantes de ingresos, como una declaración de impuestos, formulario W-2, talones de pago recientes o estados de beneficios.
