Anxiety Child Screener Form | Anxiety Specialists of Atlanta

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Child Screener Form

Thank you for your interest in Anxiety Specialists of Atlanta.

We appreciate that you are considering us to be part of your healthcare team.

This screener is for anyone under the age of 18 or for parent/caregiver interventions for your minor. If the request for new patient services is for someone over the age of 18, please fill out the “Adult Screener.”

This screening process is in response to the high volume of requests we get for new patient appointments. We believe this briefer screener will increase our efficiency and accuracy in determining whether our clinic is an appropriate fit for your needs. We will do our best to match you with a therapist whose background and availability address the information provided below. If we are unable to do so, we will do our best to provide you with appropriate referral resources.

For child and adolescent populations, Anxiety Specialists of Atlanta primarily treats OCD and anxiety disorders. We are not an appropriate fit for individuals with self-harm, aggressive or defiant behaviors, substance abuse, severe neurodevelopmental disorders, or more serious mental illness.

For additional information about the disorders we treat, please visit our website.

Child Screener Form

Screening process for new patient appointments under the age of 18.

"*" indicates required fields

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WAITLIST

Given the high volume or requests for new services, we are working off a waitlist system to best manage responding to all inquiries.

What does this mean for you? If you fill out the New Patient Screener Form, you will:
1) immediately be added to the waitlist
2) you will receive a notification, by EMAIL, that we have received your request for services and that you have been added to the waitlist, assuming your needs meet what our team offers (if you do not receive an email confirmation within one (1) business day, please contact our Practice Manager, Jessica Kalin, at 678-825-2320 by pressing 1.)
3) Once a spot is open, our intake coordination team will contact you by PHONE as soon as a space becomes available at the number you listed below. We will reserve that spot for 48 hours. If we do not hear back from you, we reserve the right to free up that spot for the next person on the waitlist.
4) If for any reason we will not be able to provide the services you have requested, we will do our best to contact you to offer referrals and other treatment options
5) For any additional questions, please contact the Practice Manager, Jessica Kalin, at 678-825-2320 by pressing 1.

YES, I have read this information understand that there is a current waitlist for available services

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Telehealth Services*

Please check to indicate that you understanding that treatment sessions are currently being held both via telehealth and in person. When visiting our offices in person, masks are required to enter our building, though they may not be required in the therapy session.

YES I have read the telehealth notification

Insurance*

Anxiety Specialists of Atlanta does not accept insurance, we are not in-network, but we are considered Out of Network (OON) providers. Therefore, every patient/family is provided all invoicing and superbills necessary to submit for claims. You can check with your insurance company to see what your OON benefits are and what your deductible is to start receiving reimbursement for OON services. Please check the box to confirm, YES, you understand this.

YES I am aware that Anxiety Specialists of Atlanta does not participate in any insurance panels, is only Out of Network, but does provide a superbill for me to file with my own insurer

Referral*

We may refer you to another practice or type of treatment following review of this screener or at any time after an intake has been scheduled if it is determined this would be the most appropriate clinical recommendation.

YES I am aware completion of this form does not guarantee I will be treated by Anxiety Specialists of Atlanta.

If you have questions you'd like to discuss by phone, please contact our Practice Manager, Jessica Kalin, at 678-825-2320, but if you are calling for a new patient appointment, you must complete this form.

If this screener is being filled out by someone other than the Minor (THE PATIENT), please answer the following information, otherwise, Skip

Name*

First Last

Your relationship to the minor

Phone Number*

Email*

Personal Information for the Minor (The Patient)

Name of the Minor (THE PATIENT)*

First Last

Email of the Minor (if applicable)

Date of Birth of the Minor*

MM slash DD slash YYYY

Phone of the minor (if applicable)

Gender of Minor*

Male

Female

Non-Binary

Other

What is the minor's current educational setting? Please check all that apply.*

Public School

Private School

Exclusively Virtual School

Home Schooled

Temporary Homebound Education

The minor is not in school

Other

If the minor is in school, please provide school name and grade.

How did you find out about us? (Check all that apply)*

Internet search (e.g., google)

Referral from therapist or psychiatrist

Referral from other healthcare provider

Family member or friend

Professional organization search (e.g., IOCDF, ADAA, ABCT, ABPP, GPA, APA, etc)

Former or current patient we see

Referral from employer of school

Other

Name of Referral*

Does the minor reside in the state of Georgia*

Yes

If the minor does not reside in Georgia, does he/she reside in any one of the other participating states that many of our therapists are legally permitted to provide telehealth services in, including Alabama, Arizona, Arkansas, Colorado, Connecticut, Commonwealth of the Northern Mariana Islands, Delaware, District of Columbia, Florida, Idaho, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, or Wyoming?*

Yes, the minor resides in one of the states listed above

No, the minor does not reside in one of the states listed above

What state does the minor live in from the options above?*

Our team specializes in treating the following anxiety, OCD, and related concerns. Which of these are primary concerns for the Minor?*

Separation Anxiety

Selective Mutism

Social Anxiety

Specific Fear/Phobia

Panic Attacks

Generalized Anxiety

Obsessive-Compulsive Disorder (OCD)

Body Dysmorphic Disorder

Health Anxiety/hypochondriasis

If you checked OCD up above as a primary focus for treatment, which themes or subtypes are CURRENTLY problematic? Please check all that apply.*

Contamination Concerns (eg. worries about dirt, germs, illness, chemicals, etc)

Harm/Aggression Concerns (eg. worries about harming self or other, worries about offending others, hit and run driving concerns, etc)

Relationship (ROCD) Concerns (eg.worries about fidelity, perfectionism about one's partner, excessive doubts re:relationship, etc)

Excessive Doubting (eg. concerns about one's memory, uncertainty about past events, etc)

Health Concerns (eg. worries about one's health or health of loved ones, worries about mental health diagnosis

Religious Concerns (eg. worries about faith, sacrilege, offending god, etc)

Sexual Concerns (eg. unwanted sexual thoughts, can be about family, children, thoughts or worries counter to one's sexual identity)

Hyperawareness/Sensorimotor Concerns (eg. awareness of breathing, swallowing, or other body sensations)

Checking Behaviors (eg. checking locks, appliances, emails, body)

Excessive Washing/Cleaning Behaviors (eg. hand washing, toileting routines, showering)

Excessive Collecting Behaviors (eg. difficulty throwing things away)

Reassurance Seeking

Ordering/Arranging Behaviors

Perfectionism

I don't feel comfortable answering

I don't know

Members of our team also specialize in treatments for the following. This means that availability of therapists might be limited. Which of these are primary concerns for the minor?

Depression

Hair-Pulling/Skin-Picking (BFRBs)

Feeding Aversions/ARFID

Misophonia

Tics/Tourettes Syndrome

Sleep Difficulties

Anxiety among individuals on the Autism Spectrum

Parent/caregiver involvement is a standard of care for our team when working with child/adolescent populations. My expectations of my participation in treatment are best described by the following answer(s):*

Parent/caregiver 1:1 with a therapist as part of my child's standard treatment

Parent/caregiver 1:1 with a therapist separate from my child's treatment

Group with other parents/caregivers (when available)

I'm open to any format of participation recommended by the therapist

There are other common problem areas that may co-occur with or be separate from anxiety that we do not treat as primary conditions. We may be able to support progress with regard to the following, however, it is very important that we know whether these are present, and we may request more information, or we may be required to refer you to other specialists prior to or during the course of treatment:

Attention Difficulties

Learning Difficulties

Social Skill Difficulties

Impulsivity

Acting out/Defiance

Anorexia or Binge Eating Difficulties

Trauma/PTSD

Please let us know if any of the following events or actions have occurred in the last 6 months as it relates to your MINOR:*

Acting out with physical aggression

Substance use

Suicidal behaviors

Self-injury (non-suicidal, e.g., cutting)

Hospitalization for psychiatric needs

Manic Episode in the context of Bipolar Disorder

N/A

Please describe the primary goals for seeking treatment*

Please indicate if you have a preference of the location of therapy services.*

In person only

Video Telehealth Only

Both In person and Telehealth

No preference

Please indicate if you have a preference of the gender of the therapist.*

Female Preferred

Male Preferred

I don't have a preference

Have you been hospitalized for safety concerns or substance abuse treatment in the last 3 months?*

Yes

If we are able to offer you a new patient intake, would you prefer we email to simply enroll you as a new patient or would you prefer a brief phone call from our practice manager to gather the necessary information for new patient registration?*

Phone Call

Either is fine

Are there any questions we can answer for you by email regarding our services, policies, or procedures for new patients?

Newsletter*

Yes, I would like to subscribe to the Anxiety Specialists Of Atlanta newsletter/email updates

No, I would not like to subscribe to the Anxiety Specialists Of Atlanta newsletter/email updates

Thank for completing this screener. We will do our best to be in touch within 24 hours (1 business day).

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1360 Center Drive Suite 200
Dunwoody, Georgia 30338
Phone: 678-825-2320
Fax: 1-800-511-2741

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ABOUT
LOCATIONS
SERVICES
STAFF
RESOURCES
NEW PATIENT INQUIRIES
PATIENT PORTAL
- Patient Portal
- Appointment Check-In

facebook
youtube
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