To Schedule a New Patient Appointment:
[questionnaire] [instructions] [insurance form] [established patients returning]
consent form Parent History Form for New Patients Teacher Questionnaire
- Complete the Child Neuropsychological History form (link) and return to our office. It is very important that you be as thorough as possible and not leave any sections blank unless they do not apply (N/A). If you have Smart Health insurance as your primary insurance, please send us the insurance form (link). E-mail, fax, or mail these to our office. If it is important to schedule your appointment as soon as possible, you will need to complete the history form, but you can bring the forms in person to our office to schedule the appointment (call ahead 850-994-1205 for office hours).
- Once we receive these forms in our office, we will send a link to Simple Practice to register, then we will contact you to schedule an appointment.
3. Please upload all records to Simple Practice. You should upload all records in advance (we prefer this mode as sometimes records may be forgotten at the time of the appointment and a second appointment might be necessary to review important evaluations so that the best testing plan is developed for your child).
o Child’s current or most recent IEP or 504 plan. The full IEP – not just the progress report. We don’t need copies of all the child’s IEPs, but please bring your copies to the appointment in case we need to review them.
o All psychological (testing) evaluations done by private psychologists or the school system (including Child Find). Please furnish even if you feel that the findings are no longer valid or are outdated so Dr. Hagerott can understand development and presentation over time.
o If the child is receiving OT, PT or Speech/Language therapies, please provide a copy of the most recent evaluation done by the therapist.
o Important neurological records (neurological exam report, MRI, EEG, genetics, surgical reports, etc.).
o Hearing (audiological) and vision tests, if impairments are present which cannot be corrected with glasses/ hearing aides.
o Report card and school work samples, if academic concerns are present. Your teacher may send to Dr. Hagerott a Teacher Questionnaire (available here).
o Any other therapy, pediatric, developmental, psychiatric, medical or educational records relevant to the evaluation.
o If the child is adopted, please furnish any records (orphanage records, adoptions summary, court reports, etc.) with the child’s history and development prior to the adoption.
o If you are not the biological parent and the child is not in either biological parent’s care, you MUST provide the court records for adoption or guardianship. If the child has not been removed from parent care, a parent must accompany the child to the first appointment. If the child is in foster care, please have the foster care worker contact our office to determine who should sign our consent forms and who will receive copies of reports.
- Request any records needed for this appointment using the request letter [link]
Please bring to the initial appointment:
o Parent or legal guardian must accompany child to appointment.
o Picture ID and your insurance card (if we are filing your insurance).
o A current list of the child’s medications and the dosage (we will ask for this at each appointment).
o Names and contact information for the doctors you wish for Dr. Hagerott to communicate with.
o Payment for services will be collected at time of appointment. We accept cash, personal check, Visa, MasterCard, and Discover.