Adult ADHD Rating Scale Request
For CURRENT patients of practice who have ALREADY seen a clinician at Ann Arbor Psychiatry.
Date of Birth
Patient Email Address
Clinician who directed you to this request form?
PA Angela Braun
PA Austin Powell
NP Brian Phillips
PA Bruce Burkeen
Dr. Akash Kumar MD
NP Anthonia Umelogu
Erin Egan LMSW
Mary Jameson LMSW
Marlowe McLaughlin LMSW
This is a close friend or family member who will receive a 10 minute questionnaire about you and your symptoms in their email
Name of close friend or family member who will fill out CAARS Observer Report (approximately 5-10 minutes)
Email of close friend or family member who will fill out CAARS Observer Report
Phone number of person filling out CAARS Observer Report
Please enter a valid phone number.
Observer's relationship to patient
Should be someone who knows you well and can speak to your symptoms of inattention or hyperactivity.
Checking each of the following to indicate understanding and agreement. All must be agreed to for testing.
I understand the cost is $50 charged to the credit card on file NOT covered by insurance
I understand this is not a "test" for ADHD but rather goes along with a multi-part clinical interview to aid in the diagnosis of ADHD
I understand that in order for my clinician to get my results in time, I need to submit this over 24 hours BEFORE my next appointment.
I am a current patient, having already seen a clinician, and understand that my clinician will receive and interpret results.
I agree to be completely honest and truthful in filling out CAARS and working with my clinician.
I have read and agree to all of the above
Should be Empty: