For a speedier first visit, please complete the forms below prior to your visit to our office and update as information changes.

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Privacy Notice Receipt
Privacy Notice Receipt
Patient Information
Patient Information
Patient History

Notice of Privacy Practices

Notice of Privacy Practices 2017

Financial Policy

Financial PolicyWe accept most major insurance plans and we will file your claims with your carrier. Since there are so many different health insurance plans, please familiarize yourself with your insurance plan and be prepared to pay all co-payments, deductibles and balances due from prior visits, at each visit. For your convenience we accept CASH, CHECK, DISCOVER, MASTERCARD, VISA, AMERICAN EXPRESS and HSA Cards.

Before making an appointment, please verify with your insurance carrier that we are “in-network” on your plan. Your insurance card should be presented at each visit.

Unfortunately, we do not accept Medicaid/Medicare.

Please be aware that if you do not show for a set appointment, or cancel without 24 hours notice, a 25.00 fee will be assessed.

Please read, sign, and date the Financial Policy form above to indicate that you understand the financial policy set forth in the document.

Modified Checklist for Autism in Toddlers - revised

Autism ChecklistThis checklist can help you determine if a professional should evaluate your child. This simple online autism screen takes only a few minutes. If the answers suggest your child is at risk for autism, please print the checklist and consult with your child’s doctor. Likewise, if you have any other concerns about your child’s development, don’t wait. Speak to your doctor now about screening your child for autism.

Well Patient Appointment Forms

HealthHabitsAssessmentWe can’t think of one person that doesn’t want to get healthier. The only thing stopping them is that they don’t know where to start. That’s why we’ve presented five specific steps that everyone can easily fit into their busy days. From adding an hour of physical activity, to eating five servings of fruits or vegetables, you’ll see it’s the little things that make a big difference. Check ‘em out!



PHQ 2The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past two weeks. The PHQ-2 includes the first two items of the PHQ-9. The purpose of the PHQ-2 is not to establish a final diagnosis or to monitor depression severity, but rather to screen for depression in a “first step” approach. Patients who screen positive should be further evaluated with the PHQ-9 to determine whether they meet criteria for a depressive disorder.


PHQ 9The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression. The PHQ-9 incorporates DSM-IV depression diagnostic criteria with other leading major depressive symptoms into a brief self-report tool. The tool rates the frequency of the symptoms which factors into the scoring severity index. Question 9 on the PHQ-9 screens for the presence and duration of suicide ideation. A follow up, non-scored question on the PHQ-9 screens and assigns weight to the
degree to which depressive problems have affected the patient’s level of function.

Children’s Mercy – Cradle Thru College Care
1004 Carondelet Drive, Suite 310  •  Kansas City, Missouri 64114  •  816-942-KIDS (5437)  •  Fax 816-942-4830