Pediatric New Patient Forms

As a new pediatric patient the following forms are required.  Please print and complete prior to your appointment.
   
1. GTHC Pediatric New Patient Packet (11 pages)  
2. Immtrac form- required for Texas Healthsteps (1 page)

If your child will be seen for an ADD/ADHD evaluation the following additional forms are required.  Please print and complete prior to your appointment.

1. NICHQVanderbilt Assessment-Parent (2 pages) and NICHQVanderbilt Assessment-Teacher (2pages)
2. Conners Parent Short form (2 pages) and Conners Teacher Short form (2 pages)

Adult New Patient Forms
As a new adult patient the following forms are required. Please print and complete prior to your appointment.

1.
GTHC Adult New Patient Packet (11 pages)

If you are an adult patient that will be seen for depression, anxiety or bi-polar disorder the following forms are required. Please print and complete prior to your appointment.
  1. Zung Self-rating anxiety scale (Spanish Form)

                                                        All Private Pay Patients (new or existing)

If you are applying for the GTHC sliding fee scale program.  Please complete the form below and return with the following information.  If you are a new patient you will need to submit the new patient packet, located above, with this form.

  1.  Last 30 days of pay stubs for yourself and spouse/partner ; and/or
  2. Current front page of the 1040, 1040A or 1040EZ for yourself and spouse/partner; and/or
  3. Letters from employers stating average weekly or monthly income for yourself and spouse/partner; and/or
  4. Unemployment statements for yourself and spouse/partner; and/or
  5. Child support statement for yourself and spouse/partner; and/or
  6. A signed and dated letter from the person(s) supporting yourself and spouse/partner.  The letter must include the dollar amount received weekly or monthly
  7. A recent utility bill for the address you have listed on the application, or
  8. Current driver’s license with the address on the application
  9. Your picture ID or drivers license (if  patient is a child)
  10. SS card for parents and child