Developmental & Behavioral Pediatrics Questionnaires
New Referrals: Intake Questionnaires
Once a referral has been initiated to our clinic, we will send you a questionnaire in the mail for you to complete and return. When the questionnaire is returned, we will give you a call or send you a MyChart message to confirm your placement onto the wait list for an appointment. If you would like to print a copy of our questionnaire to complete and send in ASAP, please select the appropriate questionnaire below:
- Questionnaires for children 0 – 3 years old: English/Español
- Questionnaires for children 3 – 5 years old: English/Español
Submitting Completed Paperwork & Previous Evaluations
Mail to:
Division of Developmental & Behavioral Pediatrics
225 East Chicago Avenue, Box 119
Chicago, IL 60611-2605
OR
Fax to:
312.227.9271
Existing Patients: Questionnaires
The questionnaires below may be requested by your provider. If you have been asked to complete any of the questionnaires listed below, please save or print a copy as needed.
Vanderbilt Questionnaire Forms
Spence Questionnaire Forms
- Parent form: 3 – 6 years old / 7 years and older
- Teacher form: 3 – 6 years old
- Child form: 8 years and older
Scared Questionnaire Forms