Adult ADHD Rating Scale Request

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 *

Month Day Year
Date
Patient Email Address *
example@example.com
Clinician who directed you to this request form?

Dr. Akash Kumar MD NP Anthonia Umelogu NP Brian Phillips PA Bruce Burkeen PA Christine Burkeen PA Angela Braun Annen Weber Dr. Mishra Dr. Sulier Erin Egan LMSW Mary Jameson LMSW Marlowe McLaughlin LMSW
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.
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.
Signature

Clear
Today's Date *

Month Day Year
Date
Should be Empty:

Adult ADHD Rating Scale Request

Observer Information