General Forms

If you have questions about filling out these forms please call the office at (503) 452-8002 or email info@childrensprogram.com.

The forms below are offered in a fillable PDF format, they require you have Adobe Acrobat Reader to download, display and print properly.  Please download the form first, complete and email it to our secure address: paperwork@childrensprogram.com or submit to our fax number, (503) 452-0084.

If you email images, rather than PDF attachments of your paperwork, you must also mail the actual forms to us or drop them off at the clinic (slide them under the door).

Forms should be submitted several days before the appointment so your clinician has time to review the information.

You only need to complete one of the packets below, either a client packet or a group packet.

Please check your printer settings, be sure to print each page individually not two-sided or duplex. 

1. Release to Disclose Confidential Information*: PDF

2. New Client Registration Packet*:  PDF   Do not fill out this packet until you have spoken to our Intake Specialist.           

3. Speech/Language New Client Registration Packet*: PDF   Do not fill out this packet until you have spoken to our Intake Specialist.

4. Adult Client Registration Packet*: PDF   Do not fill out this packet until you have spoken to our Intake Specialist. 

5. Returning Client Packet*: PDF   Do not fill out this packet until you have spoken to our Intake Specialist.        

6. Speech Financial Information and Development Questionnaire (for current or returning clients)*: PDF

7. Consent for Telehealth Services (online form)

8. Stored Pay (online form)

9. The Incredible Years Packet and Calendar Fall 2018: PDF

10. Consent for Use of a Language Interpreter: PDF

11. Consent for Use of a Language Interpreter – Spanish: PDF

12. Vanderbilt Assessment Scale – Parent: Fillable PDF  

  • download before completing on your computer, then send in as an attachment to an email.

13. Vanderbilt Assessment Scale – Parent: Printable PDF  

  • print hard copy before completing, then mail or scan/email to the clinic.

14. Vanderbilt Assessment Scale – Teacher: PDF

  • download before completing on your computer, then send in as an attachment to an email.

15. Vanderbilt Assessment Scale – Teacher: Printable PDF

  • print hard copy before completing, then mail or scan/email to the clinic.

*To view and print a list of individual forms contained in these packets click here.

Please note, some of these forms require Adobe Acrobat to display and print

Please send questions or comments to webmaster@childrensprogram.com