Adult ADHD Rating Scale Request
For CURRENT patients of practice who have ALREADY seen a clinician at Ann Arbor Psychiatry.
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Patient Email Address
*
example@example.com
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
Annen Weber
Dr. Mishra
Dr. Sulier
Erin Egan LMSW
Mary Jameson LMSW
Marlowe McLaughlin LMSW
Dr. Aaron Sedlar
PA Roopa Kline
Observer Information
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)
*
First Name
Last Name
Email of close friend or family member who will fill out CAARS Observer Report
*
example@example.com
Phone number of person filling out CAARS Observer Report
*
Please enter a valid phone number.
Format: (000) 000-0000.
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 understand that if I can show the clinic evidence of significant financial hardship that the clinic will absorb the cost of this test. The first step would be to call 734 707 1052
Signature
Today's Date
*
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Month
-
Day
Year
Date
I have read and agree to all of the above
Should be Empty: