Patient Forms

Getting Ready for Your Teen’s Mental Health Visit

These are forms that Dr. Timothy Blumer uses when treating children or teens. Samaritan Mental Health Family Center will let you know which forms to fill out. Click on the form name to open or download.

• ADHD rating scale IV (home version).
• ADHD rating scale IV (school version).
• ADHD rating scale IV (self report version).
• Mood disorders questionnaire.
• Mood chart (blank).
• NIMH child life chart method.
• SCARED – Screen for child anxiety related disorders (to be filled out by the child).
• SCARED – Screen for child anxiety related disorders (to be filled out by the parent).
• Social skills assessment (parent form).
• Y-BOCS symptom checklist.
• Youth Mania Rating Scale (parent version).
• Youth Mania Rating Scale.

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