New Patient Information
Getting Started
I am looking forward to getting to know both you and your child, so that I can best help with optimizing their development and/or behavior.
To start the process of scheduling your first appointment, please click on the link below to fill out and submit the New Patient Registration Form
Patient Portal through Charm Health (previously Athena)
Once you have contacted my office to register your child as a patient in my clinic you will receive an email with a link to create a patient portal account for your child.
The next steps are to complete the Health History Form within your child’s portal account, and to read and sign the Clinical Forms and Documents, which includes Practice Policies, Privacy Policy, Consents for Evaluation and Treatment including via Telehealth, as well as forms related to billing/payment. The forms are fillable PDFs that will be sent to your child’s patient portal attached to a message. They need to be printed to sign and sent back attached to a message in the patient portal.
Clinical Forms for Download
There are also links to fillable PDF versions of the Clinical Forms and Documents are available here, which can be completed and sent back as an attachment to a message in your child’s patient portal or as an attachment to Dr. Cohen’s HIPAA secure email (Samantha.Cohen@hushmail.com).
The Health History Form includes questions about your family history, and your child’s medical history (i.e. birth history, past medical conditions and/or surgeries, medications, allergies, etc.).
Completing and submitting the Clinical Forms and Documents, and Health History Form within the patient portal are the first steps that need to be completed prior to scheduling our initial visit.
New Patient Evaluation Packet
There is also a New Patient Evaluation Packet for you to complete using an online HIPAA compliant form. Please click on the link below to access it. Reviewing the information you share in the New Patient Evaluation Packet and Health History are the initial steps in the assessment process, and need to be completed at least 72 hours before our first appointment so that I can review the information you shared prior to our visit.
In addition, there are some standardized questionnaire(s) that parents and teachers (if applicable, or another significant person in your child’s life - daycare provider, therapist, coach, etc.) will be asked to complete prior to the initial visit.
I appreciate the time you put into completing these forms and questionnaires, as it provides me with important background information about your child, and it is an essential part of my comprehensive assessment.
CHADIS (Comprehensive Health and Decision Information System)
To streamline part of the assessment process related to completing standardized parent and teacher questionnaires I have partnered with CHADIS and the Western Psychological Services (WPS) Online Evaluation System. Both are secure, online, HIPAA-compliant services that allow you and other important people in your child’s life to complete and return standardized parent and teacher questionnaires. The information gathered from these standardized tools will help me to get a well-rounded picture of your child both inside and outside of the home setting. There is information about how to register for CHADIS below, and if applicable, a secure link to questionnaire(s) from WPS will be emailed to you to complete.
Prior Assessments
If your child has had any prior assessments related to your concerns, please share copies of those reports with me as well so that I can review that information as part of my assessment. You can send them as an attachment to a message in the patient portal, a secure email, or they can be faxed to 626-314-5242 to be uploaded into your child’s chart.
Examples of prior assessment results that are helpful for me to review include reports from High Risk Infant Clinic evaluations, California Early Start and/or Regional Center evaluations, psychoeducational evaluations (i.e. the initial and/or triennial assessments) done through the school district as part of an Individualized Education Plan/ IEP, pediatrician and/or developmental behavioral pediatrician assessment(s), psychological and/or neuropsychological evaluations, as well as therapy evaluations (i.e. speech, occupational, physical and/or behavioral therapy evaluations).
I appreciate the time that you take to complete the Health History Form, New Patient Evaluation Packet and standardized questionnaire(s) sent via CHADIS and/or WPS. Your responses will provide me with important background information about your child, and are an essential part of my comprehensive assessment.
Contact Us
Please use the contact form to let me know if you have any questions, including questions about my the forms or questionnaires prior to completing them. To schedule our initial intake visit, please complete and return the forms, questionnaire(s) ,and send any reports from prior evaluations (if applicable). Thank you for your interests in working with me to support your child!
Please note: This form is intended for general questions only. Any details regarding patient information should be sent using a HIPAA secure modality: either the form on our contact page or via Dr. Cohen’s HIPAA secure email: Samantha.Cohen@hushmail.com.