DIRKSEN CENTER RESOURCES
Forms
Below are a list of forms you can download and fill out to expedite your first visit at The Dirksen Center.
- Consent for In Person Services (download)
- Dr. Courtney Dirksen Electonic Form Bundle (download)
- Dr. Tria Murphy Electronic Form Bundle
(download)
- Dr. Lauren Laake Electronic Form Bundle
(download)
- Dr. Lisa Sorensen Electronic Form Bundle
(download)
- Dr. Karen Burcham Electronic Form Bundle (download)
- Demographic Form (download)
- Pediatric Update Form (download)
- Pediatric Questionaire (download)
- Discharge Guidelines For Pediatric Brain Injury (download)
- Alternate Caregiver Consent Form (download)
- Authorization for Release of Confidential Information from DCN(download)
- Authorization for Release of Confidential Information to DCN(download)
- Authorization for Exchange of Confidential Information (download)
Brochures
Pediatric Neuropsychology Brochure (download)
An educational pamphlet brought to you by the Public Interest Advisory Committee, Division 40 (Clinical Neuropsychology), American Psychological Association providing an overview of a neuropsychological evaluation.
Race Program Post-Concussion Follow-Up Care Brochure (download)
This brochure identifies the four components of the comprehensive RACE Program to help monitor symptoms of a concussion, provide education, and create a plan for return to school and/or activities.
Attention Deficit Hyperactivity Disorder (ADHD) (download)
The ADHD Rack Card outlines three subtypes of ADHD and provides an overview of the diagnosis process.
Traumatic Brain Injury in Children (TBI) Rack Card (download)
This card highlights what a Traumatic Brain Injury involves and the steps necessary to recover from a TBI including neuropsychological follow-up.
Websites
Concussions:
- www.cdc.gov/concussion/index.html - Centers for Disease Control and Prevention website on a type of traumatic brain injury caused by a bump, blow, or jolt to the head which can range from mild to severe. Discusses signs and symptoms, what to do to, prevention, and additional information and resources.
- www.nlm.nih.gov/medlineplus/concussion.html - Medline Plus, a service of the US National Library of Medicine and National Institute of Health gives an overview of brain concussions, a common type of sports injury, or if you suffer a blow to the head, or hit your head in a fall.
- www.mayoclinic.org/diseases-conditions/concussion/basics/definition/CON-20019272?p=1 - Mayo Clinic website on the definition, symptoms, causes, risk factors, complications, tests and diagnosis, treatments and drugs, as well as prevention of concussions.
ADHD:
Autism:
- The Autism Society of Illinois (630-691-1270) also provides educational services and support for families dealing with children on the spectrum of autism (www.autismillinois.org).
- For web information regarding autism spectrum disorder, we recommend www.autismspeaks.org for current, reliable and valid information.
855 E. Golf Road, Suite 2139, Arlington Heights, IL 60005 • (847) 357-9158
Copyright 2019, Dirksen Center for Neuropsychology, All Rights Reserved.