Note to Parents
If your child is scheduled for an appointment with a provider at one of our clinics to be evaluated for Attention Deficit Hyperactivity Disorder, also known as ADHD. You MUST fill out the Vanderbilt evaluation forms prior to the appointment. Please make sure to complete your form and ensure that your child’s teacher complete theirs.
Please remember that Community Health Centers of Southeastern Iowa, Inc (CHCSEIA), like other health organizations, depends on scheduled appointments in order to provide quality care to all of its patients. Every scheduled appointment is time specifically reserved for the provider and that patient. If you find that you were not able to complete the required forms prior to this visit, please call to reschedule.
It's our privilege to be a member of your health care team and we look forward to seeing at your scheduled appointment.
Sincerely,
Community Health Centers of Southeastern Iowa, Inc.
Online Vanderbilt Forms
below are online fillable Vanderbilt forms. if you would like to access a printable version of all the forms. please click the button below.
If you are a teacher looking to fax or mail this form please utilize the information below.
Return To:
CHCSEIA Pediatrics
Mailing:
1706 West Agency Road
West Burlington, IA
Fax:
(319)-752-4653