Phone: (901) 287-5220 Fax: (901) 287-4502

Rev. 02/25/2005 03A-01

Center for Pediatric Neuropsychology Le Bonheur Children’s Medical Center

777 Washington Ave., Suite P235 Memphis, TN 38105

Dear New Patient, You are scheduled for an initial evaluation on ___________. You will need to bring your child with you to these visits. Please bring your insurance card(s) to your visit initial visit. Your co-pay is expected at time of services as well as any deductible that applies. It is your responsibility to determine whether we are a provider for your insurance company. If you anticipate any problems with your insurance paying for these services arrangements can be made through this office to set up a payment plan. If Dr. Brewer is not listed as a provider with your plan, check with your human resources department. Because Dr. Brewer is one of few pediatric neuropsychologists in town, many plans give approval for her to be treated as an in-plan provider. We can assist you with this if needed. It is important to keep your appointment. If you are unable to make your appointment we need to know 48 hours in advance of your appointment. As our schedule is generally full weeks in advance, this allows us to place other patients in that time slot. Please come 15-20 minutes prior to your appointment to complete paperwork. The initial evaluation usually takes one hour. We reserve the right to reschedule anyone who arrives 30-40 minutes late for an appointment. If Dr. Brewer determines that neuropsychological testing is necessary, an appointment will be scheduled following your initial visit. The neuropsychological examination requires 3-6 consecutive hours of our patients time. To ensure that your services are rendered as soon as possible, please make any appointments prior to leaving our office. Please bring with you a referral from your primary care physician if required, referring physician records, school records, other records, or have them sent to us.

Sincerely, Staff of CPN

Center for Pediatric Neuropsychology

Le Bonheur Children’s Medical Center 777 Washington Ave., Suite POB 235 Memphis, TN 38105

What is Neuropsychological Testing? Neuropsychological testing involves a battery of standardized tests given by a neuropsychologist to measure the way the brain functions. Neuropsychological evaluations are often used to detect neurologic diseases or the impact of damage to the brain on functioning. Additionally, Neuropsychologists are asked to monitor recovery or progression of central nervous system disorders. Who is a Neuropsychologist? A Neuropsychologist is an individual with training in the neurosciences and the administration of tests to measure brain-behavior relationships. Why does my doctor want me to have this done? Neuropsychological testing can help your doctor in diagnosing your illness,

planning your treatment or rehabilitation, and in determining if there have been any changes in the way your brain functions since a previous evaluation. While a CT or MRI can give information about the structure of the brain, and an EEG describes its electrical activity, Neuropsychological testing tells your doctor about how your brain is working in regard to higher brain functions. What can I expect the day of my evaluation? The typical evaluation takes 3 -6 hours to perform. No invasive procedures are involved. Will my insurance pay for this service? Neuropsychological services are considered by insurance companies a medical procedure. Most insurance companies will pay for this service. We will make efforts to determine your

coverage for this procedure and will file claims for you with the insurance company. Where will my test results go? After testing is completed, the results will be discussed with the doctor who referred you for testing and a report will be prepared and forwarded to your doctor's office. Additional Questions? If you have additional questions concerning this procedure, please feel free to contact us at 572-5220. Center for Pediatric Neuropsychology 777 Washington, Suite P235 Memphis, TN 38105 901-287-5220

03A-03

Center for Pediatric Neuropsychology

NEW PATIENT INFORMATION

Asterisked (*) items are necessary for the Center for Pediatric Neuropsychology’s Medical Information System. Marital Status *Patient’s Name: M S W D Sep *Birthdate: / / Last First Middle *Street Address: Age: Sex: *SS#: / / *Home *City: *State: *ZIP: Phone: ( ) *Patient’s Relationship to Insured: (circle one) Self Spouse Child Other Marital Status

RESPONSIBLE PARTY/PARENT/GUARDIAN INFORMATION

*Name: M S W D Sep *Birthdate: / / Last First Middle *Street Address: Age: Sex: SS#: / / *Home City: State: ZIP Phone: ( ) Occupation: Employer: Yrs. Employed Employer’s Address: Work Phone: ( ) Street No. City/State/Zip *Primary Physician: ( ) Attorney: ( ) Phone No: Phone No: *Referring Physician: ( ) Phone No.

INSURANCE INFORMATION

Name of Insurance Company

Name of Policy Holder Member ID/Subscriber ID/Policy #

Group/Account Number

Street Address/P.O. Box

City/State/Zip Phone Number Policy Holder D.O.B.

Secondary Insurance Company

Name of Policy Holder Member ID/Subscriber ID/Policy #

Group/Account Number

Street Address/P.O. Box

City/State/Zip Phone Number Policy Holder D.O.B.

Medicare Number Effective Date Medicaid Number Effective Date

PLEASE PRESENT INSURANCE CARD(S) TO RECEPTIONIST FOR PHOTOCOPYING

I have completed this form fully and completely, and certify that I am the patient or parent/guardian of the patient authorized to furnish the information requested. I understand that even though I have some type of insurance coverage, I am responsible for payment of services. Patient/Parent and/or guarantor(s) agree to pay reasonable attorney’s fee and cost of collection if patient’s account is placed in the hands of an attorney for handling. I hereby authorize Center for Pediatric Neuropsychology to release any information acquired in the course of my examination or treatment for the purposes of determining elibibility for benefits and claim processing. Furthermore, I hereby authorize payment directly to Center for Pediatric Neuropsychology of the medical benefits otherwise payable to me for the services rendered. I understand that I am financially responsible for any charges not covered by this authorization. I agree a photographic copy is as valid as the original. Signature of Patient or Responsible Party Date Rev. 11/2/2005 01A-01

Center for Pediatric Neuropsychology

Children’s History Form

INSTRUCTIONS TO PARENT OR GUARDIAN: This form must be completed and returned to the Center for Pediatric Neuropsychology before your child’s appointment. Please fill out the form to the best of your knowledge. If some questions do not apply to your child, write in NA. If you need more space or wish to make additional comments, please do so on a separate sheet of paper and attach it to this form.

Child’s Name: Date of Birth:

Home Address:

Telephone:

Mother’s Name: Father’s Name:

Business Address (Father/Mother)

Business Phone:

Pediatrician:

Address:

Telephone:

Neurologist:

Address:

Telephone:

School Currently Attending: Grade:

Address:

Telephone:

Reason for Consultation:

Referred by:

Name of person filling out this form:

Date: Relationship to Child:

Rev. 8/31/96 02A-01 1

PREGNANCIES

Was this child adopted?

Did you have any of the following complaints during this pregnancy? If so, indicate the month:

Anemia: High Blood Pressure Swollen Ankles

Kidney Disease Heart Disease German Measles

Toxemia Staining Bleeding Vomiting

Rh or other blood incompatibility Virus Other

(If yes, please specify what other disease was present)

Threatened miscarriage or early contractions

Chronic illness(s) such as diabetes, kidney infection, thyroid, epilepsy, etc.

Other illnesses during pregnancy:

Hospitalization When Where

Operations

Injury

Which medications, if any, did you take during this pregnancy?

Did you consume alcohol during this pregnancy?

If so, how much and how frequently?

Did you have any other complications?

List all of your pregnancies in order, including the child to be seen at the clinic. If a pregnancy ended in

miscarriage, state at which month. If you have had more than six pregnancies, continue on the back of

this page.

Year Name Length of Pregnancy

Birth Weight

Sex Complications

Rev. 8/31/96 02A-01 2

BIRTH HISTORY

Name of Hospital

Did you have a Cesarean Section? If yes, why?

How many hours from the first contraction to birth?

Were you given medication? What kind?

Were you under anesthesia during childbirth?

What kind of anesthesia?

Was labor induced? If yes, why?

How was labor induced?

Was the baby born head first?

Were forceps used?

Did the baby have any bruises?

Did the baby have any birthmarks? If yes, how many?

Was this a multiple birth? If yes, how many?

Did this baby have breathing problems?

Was the cord around the neck?

Did the baby cry quickly?

Was the baby’s color normal? If no, was the baby blue or yellow?

If the baby was yellow (jaundiced), did he/she receive:

oxygen? How long?

transfusions? How many?

phototherapy (lights)? How many days?

Were there any other complications before you took the baby home? If so, what?

Was the baby placed in an incubator or a special crib? If so, for how long?

How long after the birth did you take the baby home?

EARLY HISTORY

GENERAL:

Did the baby have any feeding problems? If so, please describe

Was the baby colicky? If so, for how long?

Did the baby require formula changes? If so, please describe

Rev. 8/31/96 02A-01 3

Difficulty sucking as an infant?

Difficulty chewing?

Drooling past 2 1/2 years?

Was the baby normally active? If no, please describe

Was the baby limp?

Was the baby stiff?

Did the baby show unusual trembling?

Did the baby fail to grow normally?

Did the baby fail to gain weight normally?

Was this baby different in any way from his/her brothers or sisters? If so, please describe

MOTOR MILESTONES:

Age sat alone Age tied shoes Walked alone

Age pedaled tricycle Age fed self Age rode bicycle

Age dressed self Age swam

LANGUAGE MILESTONES:

Age spoke first words

Age put 2-3 words together

Age used good sentence structure

Speech problems? If so, describe

TOILET TRAINING:

Age trained for bladder for bowels

Bed wetting? Yes No Age started How often? Age controlled

Did he/she have urine accidents during the day?

Did he/she have soiling?

MEDICAL HISTORY

Has your child had meningitis or encephalitis? If so, at what age?

Has your child has a head injury? If so, was there a loss of consciousness?

Did your child have any significant injuries?

Has your child ever had a high or prolonged fever?

Rev. 8/31/96 02A-01 4

Did he/she have frequent ear infections?

Does he/she have any visual defects?

Does he/she have any hearing defects?

Does he/she suffer from heart disease?

Does he/she have asthma?

Has your child had episodes of unconsciousness?

Has your child been hospitalized?

List any other uncommon childhood illnesses your child has had:

Does your child frequently complain of:

Headache Nausea

Weakness Stomachaches

Dizziness Chronic Constipation

Chronic Diarrhea

Trouble with vision

Trouble with hearing

Any other frequent complaint?

List any medications that your child has taken in the past for more than a month (include dosage given

and the reason it was taken):

List any medications your child is currently taking (including dosage and reason for taking it):

Has your child had:

An eye exam Age Results

Hearing exam Age Results

EEG Age Results

Other special medical tests?

Have you consulted any medical specialists about your child? If so, who?

Reason

Rev. 8/31/96 02A-01 5

Results

BEHAVIORAL AND SOCIAL HISTORY

Who lives in the home?

Are there significant marital conflicts?

Are there significant conflicts between child and parents? If so, describe

Are there significant conflicts between the children? If so, describe

Who disciplines and how?

How does your child respond to discipline?

Does your child have difficulty getting along with children his or her own age?

Does your child have difficulty getting along with adults?

How does he/she occupy themselves?

Check the following characteristics that describe your child.

shy immature

well behaved stubborn

impulsive more active than other children

clumsy using his/her hands Clumsy in walking

Does your child or did your child ever have:

temper tantrums poor handwriting

sleep problems head banging

nightmares toe walking

blank spells thumb sucking

falling spells If so, describe

tics or twitching If so, describe

Difficulty staying with one activity for a reasonable length of time?

Did your child ever eat paint, paper, etc.?

Which hand does your child prefer?

Rev. 8/31/96 02A-01 6

At what age was this preference established?

Does your child switch hands?

Has your child had emotional, adjustment, or behavioral problems? If so, explain

Has your child received any psychological or psychiatric treatment? If so, by whom?

When? For what reason?

Have you consulted with anyone about the current problem? If so, with whom?

When? Where?

SCHOOL HISTORY:

Did your child attend nursery school or a preschool program?

Were there problems? If so, describe

Has the school currently reported problems with:

Behavior

Social Adjustment

Attention Span

Following directions

Completing assignments

Arithmetic

Reading

Spelling

Writing

Does your child like school?

Is your child in a special education class? If so, what kind?

When was he/she placed there?

Does your child receive any special services in school (resource room, tutorial, remedial reading, speech,

etc.)? If so, describe

For how long?

Have you gotten any help privately for your child? If so, describe

Rev. 8/31/96 02A-01 7

FAMILY HISTORY

List children in order of birth

Age Education or current

grade

Occupation Health School or Behavioral Problems

Father Mother

Did anyone in your immediate family or other relative have any of the following? (if so, who?) Neurological disease

Seizures (epilepsy)

Hearing problems

Visual problems

Emotional problems

Mental retardation

Slowness in talking

Slowness in walking

Hyperactivity

Reading problems

Learning Disabilities

Problems similar to your child

Does any disease run the family? If so, describe

Additional Comments:

Rev. 8/31/96 02A-01 8

Phone: (901) 287-5220 Fax: (901) 287-4502

Center for Pediatric Neuropsychology Le Bonheur Children’s Medical Center

777 Washington Ave., Suite P235 Memphis, TN 38105

Dear Parent, The evaluation is set up as a two part process. The first visit is designed to allow me to watch your child and get pertinent information from you so that I will know what we need to do and approximately how long it will take for us to do the evaluation. The second part is the evaluation by a technician. After the evaluation is completed, I will go through the process of interpreting the findings, writing the report, and making recommendations. You will need to schedule this when you come in for the evaluation. Billing for neuropsychological evaluations is done by calculating the number of hours for the actual evaluation, the time required to score and interpret, and the time required for writing the report and making recommendations. I have read and agree with the procedures for determining billing ___________________________ ______________________ Parent or guardian Date

V.R. Brewer, Ph.D. Director of Neuropsychological Services Le Bonheur Children’s Hospital

Chief Executive Officer Pediatric Neuropsychologist Center for Pediatric Neuropsychology

Clinical Assistant Professor of Pediatrics University of Tennessee-Memphis

Chief of Neuropsychology Neuroscience Institute

Center for Pediatric Neuropsychology Le Bonheur Children’s Medical Center

777 Washington Ave. Suite P235 Memphis, TN 38105

Phone: (901) 287-5220 Fax: (901) 287-4502

To:

Incoming Records

CONSENT AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION OR RECORDS

Patient’s name: Address: City: State: Zip: Date of Birth: / / Social Security No.: - - Authorization is hereby granted to release medical, psychological, or other information to: Center for Pediatric Neuropsychology, Dr. Vickie R. Brewer

(Specify Individual)

Limited to the following information or records: Covering treatment from:

(Specify Dates) For the purpose of:

Continuity of Care other I understand that I may revoke this consent to release information at any time. I also understand that my release shall not constitute a breach of my right to confidentiality. This authorization expires 1 year from the below date. I understand that the information released cannot be redisclosed by person(s), institutions(s) named above unless I specifically authorize such a release in writing. (Patient, Parent, or Guardian’s signature) (Date) (Relationship to patient) Rev 1/21/97 01A-03

Phone: (901) 287-5220 Fax: (901) 287-4502

CONSENT AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION OR RECORDS I authorize the Center for Pediatric Neuropsychology to release to:

(name of party to receive information)

(Address of party to receive information) City State Zip

complete record evaluation report

progress notes other

for the time period of: Patient’s name: Address: City: State: Zip: Date of Birth: / / Social Security No.: - -

Center for Pediatric Neuropsychology Le Bonheur Children’s Medical Center

777 Washington Ave. Suite P235 Memphis, TN 38105

The purpose or need for the information is:

continuity of care legal

insurance application other

I understand that I may revoke this consent to release information at any time. I also understand that my release shall not constitute a breach of my right to confidentiality. This authorization expires 1 year from the below date. I understand that the information released cannot be redisclosed by person(s), institutions(s) named above unless I specifically authorize such a release in writing. (Patient, Parent, or Guardian’s signature) (Date) (Relationship to patient) Rev 9/15/96 01A-04