ADHD & Learning Differences Program

Dear Parent or Guardian,

Thank you for choosing Children's National for your child's care. Per your request, I am sending you patient Intake Forms for the ADHD & Learning Differences Program. Our program provides families with comprehensive clinical care, including evidence-based assessment, individual, family, and group behavioral treatment. We are also an academically driven program that incorporates trainees at every level of clinical services.

We have a detailed intake process that is designed to improve efficiency and provide best service possible. In order to set up an appointment and receive appropriate evaluation or treatment services for your child or teen, we ask that you carefully fill out all the enclosed forms as completely as possible. Or if you prefer, we can email this packet to you and you can return it via email, fax or US mail to the address provided below. Once we receive your packet, our team will review the information for the appropriate clinician and appointment. You will be contacted by one of our team members as soon as an appointment date becomes available.

Enclosed are the following:

1. Contact & Insurance Information Form
2. Background History Questionnaire
3. Homework Problems Checklist, Vanderbilt Parent Assessment Scale, & Children's Sleep Habits Questionnaire

Please include a copy of the front and back of your child's insurance card.

Methods for returning your packet are as follows:

e-Survey: Follow along and complete this electronic survey

Mail: Children's National Hospital

Division of Psychology & Behavioral Health

Attn: ADHD & Learning Differences Program

6833 4^th Street NW

Washington, DC 20012

Email: ADHD@childrensnational.org

We can be contacted at: Main Number: 202-729-3300

Thank you for choosing Children's National Hospital for your child's care.

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