Forms

For some referral problems, it is very helpful to have additional information. Please complete the forms requested and drop them off at our office or fax (250-591-1913) before your appointment if possible.  Most questionnaires are used for screening purposes only and may help us to rule in or rule out certain conditions.

If your child is school age, also bring report cards to the appointment. 

1. PARENT GENERAL QUESTIONNAIRE

2. TEACHER Assessment Form

3. SNAP IV (PARENT AND TEACHER)

4. SCHOOL AGE developmental screen (WSR)

5. ADHD Functional Impairment (Weiss) Q

6. ADHD ASSESSMENT Q (Vanderbilt)PARENT

7. ADHD ASSESSMENT Q (Vanderbilt) TEACHER

8. ADHD FOLLOW UP Q (VB) PARENT

9. ADHD FOLLOW UP Q TEACHER

10. M-CHAT AUTISM SCREEN

11. AUTISM SCREEN for >6

12. AUTISM SCREEN for <6YR

13. ANXIETY SCARED Q-CHILD

14. ANXIETY SCARED Q-PARENT

15. TEEN DEPRESSION SCREEN (KADS)

16. DEVELOPMENTAL COORDINATION DISORDER Q