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  4. Patient Intake Forms

Patient Intake Forms

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Thank you for choosing our UCLA Developmental-Behavioral Pediatrics Program. To schedule an appointment please contact the Appointment Center at 310-825-0867.

Listed below are the forms and questionnaires that we will ask you to complete before you visit us in the clinic. Please download the forms and please send us the Intake Form as soon as you can, via fax, e-mail or mail can so we can schedule the initial appointment.

Additionally, please send us copies of any developmental-behavioral information about your child, including reports from daycare providers, teachers, therapists or other relevant providers (Teacher/Therapist Questionnaire). These forms ideally should be send before the visit if possible. Please bring the originals to the visit.

Email: DBP@mednet.ucla.edu
Phone: 310-794-1456
Fax: 310-206-4215

Address: Developmental-Behavioral Pediatrics Program
               300 Medical Plaza, Suite 3300, Los Angeles, CA 90095


If you are a new patient below 5 years of age:

  • New patient intake form below 5 years of age
  • Teacher/Therapist Questionnaire below 5 years of age

If you are a new patient 5 years of age and above:

  • New patient intake form 5 years and above
  • Teacher/Therapist Questionnaire 5 years and above

If you have any questions, please do not hesitate to call us at 310-794-1456.

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