Evaluation forms
These are in PDF format and contain information about the evaluation, the questionnaires and other forms. Please fill out and bring them with you.

Adult package
May be used for adults, 18 year old and older

Child Package
May be used for ages up to 22 (for college students or patients with developmental concerns). The child eval forms include a teacher questionnaire. Please take this part to school and ask a teacher who knows the child to provide the inputs. The completed teacher form can be mailed to our office by the teacher or you can bring it with you on the day of your first appointment.

Records Request Forms

Record Release – From EBPG to others

Fill out this form if you’d like EBPG to send your records to another physician or medial organization.

Records Request – From others to EBPG

Fill out this form if you’d like EBPG to request your medical records from another physician or medical organization.

Admin fee letter 2016 

This letter is an explanation of the services our yearly administration fee covers.

All forms are © Copyright of Michael Levin, M.D., 2011 All Rights Reserved.