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Douglas R. Coombs, MD 520 East Medical Drive #301 Bountiful, Utah 84010 Phone (801)292-1464 Fax (801)292-1465 Date__________________ Dear Parent/Guardian, This ADHD evaluation includes information from school as well as home. Please fill out the the following home screening scales and return them to our office one week before your office visit. Attached, please find: Structured Parent Interview Vanderbilt Parent Assessment Scale Home Symptom Screening Scale Depression Scale for Children Screen for Child Anxiety (CHILD) Screen for Child Anxiety (PARENT) Please complete these forms as soon as you can find time to do so thoroughly. If there is additional information that you consider pertinent, please provide this on an additional sheet or call us at the office. As soon as you have completed the forms, please either mail them, fax them, or return them in person one week before your office visit. If your paperwork does not arrive one week before your appointment, you will be rescheduled. If you do not show up as scheduled, you will be placed at the end of the appointment list. Please bring a quiet toy or activity for your child to play with during the consultation process of the exam. ***Not all insurances will cover the cost of reviewing, scoring or interpreting this packet. You will be responsible for any costs not covered by your insurance plan*** Sincerely, Douglas R. Coombs, MD, FAAP Lisa Sharp, RN, FNP, BC Gina M. Capps, RN, CPNP Stacey A. Bushell, MSN, CPNP Kim Webb, RN, CPNP Brian J. Holdstock, MSN, CFNP
