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Thank you for helping us better understand your concerns. We look forward to providing services to your family. This form is to be used by families after receiving contact from our office indicating that your referral has been accepted. If you have not received a referral to our psychology/psychiatry department, please talk to your child's primary care physician.

If you have any questions, please contact us at 937-641-3401. We will call you within three days of the receipt of this form to schedule an appointment.


parent/guardian Information:

background information:

developmental history

At what age did your child:

do you have concerns about any of the following for your child?


If YES, please bring a copy of the IEP to your first visit.

medications your child takes

medicationdosehow often
previous medicationdosehow often

insurance information

contact us

The psychology department can be reached during business hours of M-F 8:30 am to 5:00 pm at 937-641-3401.

5 lessons from the Olympics for kids

Every four years the world comes together to watch athletes from all over compete in the summer Olympics. The Olympic Games bring Americans together as they cheer on their favorite athletes and ultimately root for Team USA.

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