Developmental Autism Pediatrics eScreener

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Child Age* Less than 18 years old (<18) Greater than 18 years old (>18)

Mood Disorders

The Division of Developmental & Behavioral Pediatrics does not evaluate or treat children for mood disorder. Please contact your child's pediatrician or primary care provider for a referral to a more appropriate mental health specialist such as a child & adolescent psychiatrist, a clinical psychologist, or a social worker that is able to evaluate your child's mood.

You may also consider Perform Care services. Perform Care is a national, full-service behavioral health managed care organization. PerformCare is the single point of access to a wide array of behavioral health, intellectual and developmental disability services as well as substance use treatment for youth and families throughout New Jersey. To access services, call the 24 hour toll-free access line: 1-877-652-7624.

For evaluation with Child & Adolescent Behavioral Health & Psychiatry, please call 551-996-4450.

Adult or Guardian Information

Full Name*

Phone Number*

Email*

Relationship to child* Parent Foster Parent Adoptive Parent Case Worker Legal Guardian Other Other Relationship

Reason for Evaluation

What is your primary reason(s) for seeking this evaluation (select all that apply) * Speech or language delay Motor delays or poor coordination Cognitive delays or intellectual disability Possible autism or autism spectrum disorder Possible ADHD (inattention, hyperactivity, aggression, defiance) Behavioral difficulties (tantrums, aggression, defiance) Learning/academic concerns Genetic conditions Mood Disorder such as: anxiety, sadness, or depression

Previous Evaluations

Has the child been previously evaluated or received a diagnosis by the following? (check all that apply) * Developmental Pediatrician Psychiatrist

Are you seeking a second opinion for one or more diagnosed conditions?* Yes No

If you answered yes to the previous question, please provide us with additional information about the primary diagnosis.

Child Information

Child Full Name*

Child Date of Birth*

Child Address*

Child Gender* Male Female Other

Primary Care Provider / Pediatrician Name and Address*

Language spoken at home* English Spanish Other

Need for interpreter* Yes No

Child Medical Conditions

Does your child have a medical condition(s) requiring any of the following services (select all that apply) * Your child has seen three or more medical subspecialists in the last year (e.g. cardiology, gastroenterology, ENT, pulmonary) Has a genetic diagnosis/syndrome Has a diagnosed chronic medical disease ( e.g. diabetes, heart disease) Uses durable medical equipment, such as a wheelchair/ gait trainer Has a tracheostomy and/or feeding tube Family social situation that requires further assistance Other

Child Health Insurance

Child's Primary Health Insurance* 1199 Aetna Affinity Blue Cross Blue Shield Cigna Emblem Empire BCBS Fidelis GHI Healthfirst HIP MagnaCare Medicaid Northwell Direct NYSHIP TriCare United HealthCare Other

Child's Secondary Health Insurance 1199 Aetna Affinity Blue Cross Blue Shield Cigna Emblem Empire BCBS Fidelis GHI Healthfirst HIP MagnaCare Medicaid Northwell Direct NYSHIP TriCare United HealthCare Other

I attest that I have explored financial options and payments

Child is over 18

Based on your response, please note that the Institute for Child Development is unable to accept new patients that are older than 18 years old. We recommend that you contact your primary care physician. We also recommend considering reaching out to Behavioral Health & Psychiatry at 551-996-4450 or the Neuroscience Institute at 551 996 8100, as appropriate.