Forms

Please make sure that you have first contacted our office before starting the registration forms.

New Family Registration Packet This should be completed once per family.

Patient Health History This should be completed for each child being registered.

Release of Medical Records to Centennial Pediatrics of Spokane This should be completed for each child in order to obtain his/her previous medical records.

Thank you.

• Behavioral Health - Dr. Sara Streufert: Intake and History - Please complete ahead of your initial intake appointment. Thank you.
• Behavioral Health - Dr. Sara Streufert: New Patient Registration Packet - Please complete if you are NOT already a patient at Centennial Pediatrics of Spokane.

• Autism Evaluation Intake and History Please complete this prior to your first visit. Thank you.

• ADHD: Teacher Follow-Up Form
• ADHD: Parent Follow-Up Form
• ADHD: Parent Initial Form
• ADHD: Teacher Initial Form

• SCARED Anxiety Screen (parents to complete)
• SCARED Anxiety Screen (child to complete)
• PHQ-9 Depression Screening
• GAD-7 Anxiety Screening

• PHQ-9 To be completed for all check-ups for 12 years old and older.
• GAD-7 To be completed for all check-ups for 12 years old and older.