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Patient Forms
Patient Forms: Management of Children/Adolescents/Adults Affected by ADHD
These patient forms may be downloaded and printed; you may bring
completed forms with you to your visit, or mail them (in
advance) to our office:
Brainchild Achievement Center
9302 N. Meridian Street, Suite 170
Indianapolis, IN 46280
Please DO NOT email them since they may contain confidential (protected) medical information.
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Form Name
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PDF Format
(*.requires
Adobe Reader)
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MS Word Document
(*.doc format)
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Consent for Treatment
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"New Patient" Health History Form
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Notice of Patient Privacy Policies
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Record Transfer Release
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"Signature on File" Permission Form
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Accident Injury Report
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SF-12 Health Survey
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Back Pain Report Form
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Neck Pain Report Form
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X-Ray Payment Assignment Form
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Functional Assessment Form
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Note: PDF files require Adobe Acrobat Reader™ to view. To
download a free copy of Acrobat Reader in a new window -
Click Here |
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Sign Up for a Consultation
For more information about Brainchild Achievement Center and the conditions we treat, or
to schedule an appointment for consultation, call 317-843-9200, or
send us an email or submit
this short form. We will contact you as soon as possible.
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