Forms for Your First Visit

Below are the forms you or your child will need for your first appointment with Dr. Randy Kulman at South County Child and Family Consultants. Please print out and complete beforehand to bring with you to your visit.

Click any of the forms below to download a printer-friendly copy :

Background Questionnaire   |   Download (.pdf)
Patient Information   |   Download (.pdf)
Confidentiality Agreement   |   Download (.pdf)
Fee Agreement   |   Download (.pdf)
Consent for Treatment   | Download (.pdf)
Authorization of Release   | Download (.pdf)
Protocol for Evaluation   | Download (.pdf)
HIPAA – Privacy Practices   | Download (.pdf)

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: Understanding How Children Use Video Games and Other Digital Media

: Parent Form – Executive Skills Questionnaire [Ages 5-8]

: Parent Form – Brief Academic Skills Survey [Ages 5-8]

: Parent Form – Technology Assessment

: Parent Form – Brief Academic Skills Survey [Ages 9+]

: Parent Form – Executive Functions Technology Assessment Tool

: Parent Form – Multiple Intelligence Questionnaire

: Student Technology Assessment Tool

: Parent Form – The Processing Speed Questionnaire

: Technology Assessment and Survey for Kids

: Parent Form – Executive Skills Questionnaire