Download Marcus Autism Center Provider Information Form

Patient Name:___________________
Barcode goes here
Date of Birth:____________________
Marcus Autism Center
Provider Information Form
MRN:__________________________
Account/HAR#:___________________
This form is to be completed by the healthcare provider that is familiar with the care of your child. The provider can
include a pediatrician, psychiatrist, psychologist or therapist that has knowledge of your child’s development to help us
determine the appropriate referral by the Marcus Autism Center intake team.*
Fax to 404-785-9202
Patient Information
Child’s Name:
Family Name (if different):
Address (street, city, state, zip code):
D.O.B.:
Phone:
Email:
A. We offer many different services at Marcus Autism Center. To help us identify your primary concern for the
child, please select only ONE initial service (Diagnostic OR Treatment) that you determine would meet the
priority needs for the child. If more than one service is needed, additional referrals can be made by the
clinician at the time the child’s first visit.
B.
A. ☐Diagnostic Evaluation ( testing for autism) (check one below)
☐Child is 15 months or younger, and there are concerns about developmental delays and/or social
interaction.
☐ The child needs a formal evaluation to determine if the child has Autism (ASD). (Autism Spectrum Disorder,
Autism, Pervasive Developmental Disorder Not Otherwise Specified (PDD NOS), Asperger’s
Syndrome, ASD)
There are concerns with:
☐Social interactions AND communication or ☐Repetitive behaviors and/or unusual interests
☐ The child has been previously diagnosed with Autism, and family/guardians are seeking a second
opinion regarding diagnosis.
The M-CHAT (Modified Checkllist for Autism in Toddlers) screener was administered ? Yes ☐ No ☐
18 months
☐ Pass ☐ Fail # items failed ________
24 months
☐ Pass ☐ Fail # items failed ________
30 months
☐ Pass ☐ Fail # items failed ________
Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________
B.☐Treatment Services (check one below)
☐Child has a diagnosis of ASD and/or Developmental delay (required), and the family are seeking treatment
services for:
☐Problem Behaviors
☐Toilet Training
☐Feeding Problems (NO ASD or Developmental Delay Diagnosis Required)
☐Language and Skill Acquisition (Developmental Delay Diagnosis Required)
Is the child currently in speech language therapy? Yes ☐ No ☐
53840-98-IH (1/16)
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Comments:
Characteristics of Autism Spectrum Disorder
Please briefly describe the characteristics of autism spectrum disorder raising concerns (please check all that apply)
Social
Communication
Repetitive Behavior or
Restricted Interests
Other
☐Less eye contact, use of gestures or facial expression
☐Difficulty understanding the emotions and feeling of others
☐Difficulty playing with same age children
☐Problems making and keeping friends
☐Less sharing of interests with others
☐Lack of speech
☐Slow to learn speech
☐unusual speech (repeats things, speech sounds unusual)
☐Difficulty making conversation
☐Less imitation and pretend play
☐Repeating activities or movements (rocks, spins, flap hands, flicks fingers)
☐Uncommon, strong, limited interests (often talks about the same topic or plays
with same item, knows a great amount of information on topic)
☐Plays with parts of toy rather than the toy as a whole (i.e. spins wheels of toy car)
Please describe
Medical Information (check all that apply)
☐Delayed Motor Milestones (rolling, sitting, walking, etc.)
☐Delayed Language Milestones (babbling, first words, phrase or
sentence speech, etc.)
☐Periods of developmental regression (loss of motor or
language skills)
☐Premature birth (less than 37 weeks gestational age, born
more than 3 weeks early)?
☐If premature, what was your child’s gestational age at birth?
☐History of prolonged oxygen requirement (months)
☐Irregular breathing or breath holding
☐Brain bleed, intracranial hemorrhage (IVH)
☐Brain abnormality or abnormal brain MRI
☐History of brain injury, severe brain trauma
☐Epilepsy or seizure disorder
☐Muscle weakness
☐Low muscle tone, hypotonia
☐High muscle tone, hypertonia, spasticity in muscles
☐Current Tube feedings
☐Chronic Constipation / Obstipation
☐Heart defect
☐Kidney abnormalities
☐Abnormalities of the hands or feet
☐Dark or Light birthmarks on skin
th
☐Unusually tall (Greater than 98 percentile) or short (less than
th
10 percentile)
th
☐Very large head size (Greater than 98 percentile)
☐Genetic abnormality. Please describe:
☐Brother, Sister or Parent has Autism
☐Birth mother is known or suspected to have used illicit drugs or
alcohol while pregnant with this child
☐Describe any other medical issues:
☐Cerebral Palsy
☐Deaf, Hearing Impairment
☐Blind, Low Vision
☐Cleft lip, Cleft Palate, Submucous Cleft, Velopharyngeal
Insuffeciency
☐History of prolonged time on ventilator (weeks)
☐List any other medical/developmental diagnosis
☐History of Failure to Thrive, poor weight gain
☐Gastro-esophageal Reflux Disease (GERD)
☐Gastrostomy, Gastrostomy tube or button
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Psychiatry
☐Is currently under the care of a psychiatrist ☐NO ☐YES
If yes, Name of psychiatrist:
☐Has previously been given a psychiatric diagnosis (e.g. ADHD, OCD, Anxiety, Oppositional Defiant Disorder, Conduct
Disorder, Bipolar Disorder / Manic Depression, Depression, Mood disorder, Thought Disorder, Schizophrenia )
Please list:
☐Has the child ever had an inpatient psychiatric hospitalization?
Dates:
Medical records from these hospitalizations are requested for review by our medical team. Please fax records to 404-785-9202.
Medications
Is child currently taking any prescribed medications, dietary supplements, complementary/alternative treatments? ☐NO ☐YES
Please list medication(s)/dose & frequency, dietary supplements, and/or complementary and alternative treatments:
Name of physician(s) prescribing medication(s):
Referring Provider
Name:
Address :
Phone:
Email:
Signature:
Fax:
Date:
*The completion of this form is requested but not required for the review process.
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