Northwest PANDAS/PANS Network
Your LOCAL 501c3 nonprofit. Serving Oregon, Washington and Idaho.
Name:
*
First Name
Last Name
Email
*
example@example.com
Facebook name if requesting to join our parent/caregiver group
Phone Number
Please enter a valid phone number.
State
*
Please Select
Oregon
Washington
Idaho
Outside the Northwest
City
*
Have you or your child been diagnosed with PANDAS/PANS?
*
Yes
No
If yes, who diagnosed them and when?
Requesting
*
Referral to PANDAS/PANS provider
PANDAS/PANS provider list
Crisis Support
School Support (504/IEPs, etc.)
PANDAS in School System FREE book (Educators only)
Presentation by NWPPN on PANDAS/PANS for my clinic, organization, nonprofit, etc.
Other
How did you hear about our nonprofit serving the Northwest?
*
Medical provider
Behavioral health provider
Educator
Google search
Social media
Friend
Family
Conference
Presentation by NWPPN
Advertisement
Other
Child/Adult Affected Information
Current Age
*
Age at Onset
*
Symptoms you or your child is experiencing:
*
OCD
Urinary Frequency
Tics
Suicidal ideation
Eating Restrictions
Suicide attempt
Anxiety
Emotional Lability
Depression
Aggression/Rage
Behavioral Regression
Handwriting Changes
ADHD
Sensory Sensitivities
Sleep Disturbances
Urinary incontinence (Enuresis)
School refusal
Other
Anything additional you would like us to know
Submit
Who responded to initial inquiry via email?
Kym
Sarah
Carly
Sue
Sarah & Kym
Other
Response sent
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Month
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Day
Year
Date
Referred to:
Dr. Gbedawo
Dr. Paravinci
Dr. Mcallister
Dr. Hancey
Dr. Phillips
Dr. Jenny Wilson
Dr. Jain
Dr. Kovacevic
Amy Smith
Dr. Payne
Dr. Chapman
Dr. McCarty
Dr. Kirchoff
Dr. Day
Dr. Hill
Dr. Stein
Dr. Eberhardt
Dr. Messinger
Melissa Kidby
Jordan Sirtoli
Jennifer Boudreaux
Jillian Ehrlich
Dr. Plawner
Dr. Squires
Dr. Dahlgren
Dr. Derkson
Aaron Dykstra
Dr. Brus
Carey Crill
Dr. Dandy
Dr. Ohara
Dr. Kiki Chang
Dr. Wilms
Dr. Bedford
Tamara Broadhead
Dr. Doug Lincoln
Nicole Gansemer
Manuel Sierra
CPAE
Dr. Bowker
Dr. Dossetter (Kaiser)
Dr. Duft (Kaiser)
Paige McAfee
Other
Comments:
Additional Information on Case
Diagnoses to Date:
ADHD
Oppositional Defiance Disorder (ODD)
Cognitive Reframing
Autism
Mast cell
Anxiety
Thyroid condition
OCD
Immunodeficient
Ehler Danos
Lyme
Depression
Down syndrome
Role Play
Mold Toxicity
Arfid
Mirroring
Other
School Status:
Please Select
In age appropriate grade
Not in school
Home schooled
Alternative school
Special education
504
IEP
Not Assessed
Ongoing Case Notes
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Should be Empty: