Patient Forms

Mental Health Services

Our behavioral health integration program is aimed to streamline the care your child and family receive with the convenience of receiving services at a centrally located medical home that is comforting and familiar. Medical practices that have initiated an integrated practice receive feedback of greater satisfaction among patients and pediatricians as we are able to communicate seamlessly through existing records, referrals and follow-up. We are determined to meet the needs of our patients that have struggled to link their child’s services together.

Consent for Communication

Initial Consultation Survey

What to Expect

New Patient Forms

In order to help speed up the process of checking in your child for his/her first visit with us, it will be helpful to print out the following forms at home and complete them prior to your visit with us.

Patient Intake form

ACE Patient

ACE Caregiver

Consent to Treat

Policy for Divorced and Separated Parents

HIPAA Medical Release Form

HIPAA Notice of Privacy Practice Form

HIPAA Authorization for Disclosure of Information Form

Patient Contract Form

Patient’s Financial Responsibility Disclosure

Additional New Patient Forms (Newborns)

For parents of newborns, please print out the following important information about pertussis, or whooping cough. If you are interested in getting vaccinated, let the front desk know when you check your infant in for his/her first exam in our office.

Pertussis Vaccine for Families of Infants

Tetanus, Diphtheria, and Pertussis Vaccine (Tdap) Consent

School Sports Physical Forms

The different counties served by Palm Beach Pediatrics each have their own specific form for school sports physicals. As these forms change annually, we have provided you a direct link to these respective forms. Please choose the county school district your child is enrolled in, print the form, and bring it with you to your appointment. Unfortunately, we are not aware of the Martin County school district having any sports physical forms online.

Palm Beach County

Please click on FORMS SEARCH in the main menu bar at the top of the page.  In the dropdown entitled, “FORM NAME”, please find the form you are seeking under ATHLETIC ELIGIBILITY.

St. Lucie County

Please scroll down the page, almost to the bottom, and find the section in the center column entitled, “ATHLETIC RESOURCES”.  Select the respective packet of forms dependent on the age of your child.

Well Visit Forms (2 wks – 6 mos)

Maternal postpartum depression screening for mothers with children 2 weeks to 6 months of age. Please print and complete this form and bring it with you on the day of your appointment.

Edinburgh Postnatal Depression Scale (EPDS)

Well Visit Forms (18 mos – 2 yr)

18 month and 2 year Check-Ups – The M-CHAT is a screening test for Autism that we perform at these two visits. Please print and complete this form and bring it with you on the day of your appointment.

Modified Checklist for Autism in Toddlers (M-CHAT)

Well Visit Forms (4 yr – 11 yr)

We are screening for behavior issues with the Pediatrics Symptom Checklist for all children ages 4-11 year olds. Please complete prior to the well visit and the screening will be discussed with you by the provider. This form is to be filled out by the PARENT.

Pediatric Symptom Checklist (PSC-17)

Well Visit Forms (12 yr +)

We are screening for depression with the PHQ-9 in all teens from ages 12 and up. Please complete prior to the well visit and the screening will be discussed with you by the provider. This form is to be filled out by the CHILD.

Patient Health Questionnaire (PHQ-9)