Pediatricians of Dallas
Diagnostic Testing Patient Registration
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We at Pediatricians of Dallas look forward to working with you and your family!  Before we meet, please take the time to provide us with all the necessary information including the registration paperwork, parent rating scales, and teacher feedback forms.  We greatly appreciate your help in gathering all this information as it enables us to thoroughly get to know your child!
 Lee Ann Hamm, MS, LPC, LPC, NCC, Abbie Douglas, MS, LPC, and Karen Bunger, Certified Educational Diagnostician
Child's Name
Child's Date of Birth
Child's Grade (if summer, last completed)
Child's School
Child's siblings and ages
Parent/Guardian Name(s)
Marital Status  
(please provide a divorce decree or guardian paperwork if applicable)
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Address: City, State, Zip
Email
Preferred Phone number
Is this person the biological parent of the child? (If no, please explain)
Please list the people who live in the same home as your child
Is your child currently being assessed elsewhere?
Has your child ever received psychological evaluation services?
If yes, please provide us with a copy of the evaluation
How did you find us?
Please write a brief statement explaining the reasons why you are requesting services for your child
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