Douglas R. Coombs, MD
520 East Medical Drive #301
Bountiful, Utah 84010
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***
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
STRUCTURED PARENT INTERVIEW
Form Completed By
School Name/ Contact
School Phone #
School Fax #