Commitment to Inclusivity: The Ross Center is an equal opportunity organization, and does not discriminate on the basis of race, age, ethnicity, ancestry, national origin, disability, color, size, religion, gender, sexual orientation, marital status, or socioeconomic background. We are committed to providing an inclusive and welcoming environment for all patients and members of our staff. To learn why we include pronouns on each provider’s bio, click here. For any questions, or to report any concerns, please contact us at info@rosscenter.com.

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Rx Refill Request Form

Please be advised that the turnaround time for prescription refill requests is no more than 48 business hours. This means anything received on Friday will be completed no later than the same time the following Tuesday (assuming that Monday is not a holiday). If you cannot give us that much time, please call the office as soon as possible and do not use this form

Rx Request Form

Prescription Refill Form

Your Name(Required)

Patient Name (if different than above)

Patient's Date of Birth(Required)

Your Phone Number(Required)

Name of Medication - with Strength(Required)

Instructions For Use (ie once daily, twice daily, etc.)(Required)

Pharmacy Name, Address and Phone (please include all)(Required)

Name of your prescribing clinician at The Ross Center(Required)

Which Office does your clinician practice in? (Please choose from the list below)(Required)

What is the date of your next scheduled appointment (or if one has not been scheduled, when does your physician want to see you next?)(Required)

What is the date that will you be out of the medication on hand?(Required)

Email

This field is for validation purposes and should be left unchanged.

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REACH Screening Form

Thank you for your interest in our REACH group.

REACH Form

Screening form for REACH groups

Name of Person interested in the REACH program(Required)

Date of Birth of Interested Participant(Required)

Phone(Required)

Email(Required)

Do you identify as a person of color? (Please select one answer below)(Required)

Region where you will be located during the group (please choose from the list below):(Required)

Please note that participants of the REACH program must be located in the states of New York, Virginia, Washington, DC, or Maryland to participate in this program. The group will be delivered virtually.

How did you hear about The REACH program? If you were referred by a health care provider, please include their name:

Comments

This field is for validation purposes and should be left unchanged.

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Supportive Parenting for Anxious Childhood Emotions (SPACE) Screening Form

Thank you for your interest in our SPACE-informed parenting group. Our group is designed to work with parents of children whose primary difficulty is anxiety with related avoidance behavior. Please answer the following questions so that we can gain a better understanding of you and your child.

SPACE Form

Parent/Caregiver Names:

Marital Status:

Child’s Name:

Child’s age:

Child’s DOB:

Child's Grade in School. *Please note this group is for children in grades K-12:

Email:

Phone:

Home Address:

Street Adress City State / Province / Region ZIP / Postal Code

Please list the U.S. state you will be located in during the group:

The SPACE group is open to residents of any of the 32 states where psypact has been enacted. Psypact is a program that allows licensed therapists to practice virtually in approved states. See the web page to ensure that your state is included.

Participants

Who is seeking to participate in the SPACE group? (Please specify each participant’s relationship to the child.)

Diagnosis

Has your child ever been diagnosed with a mental health disorder? If so, please explain:

Treatment

Is your child involved in any mental health treatment (i.e., parent coaching, individual therapy, medication management, family therapy, etc.?) If yes, please list the name of the treatment provider and type of treatment.

Hospitalization

Has your child ever been referred to or participated in an intensive outpatient treatment, partial hospital program, or inpatient hospitalization? If yes, please explain and include dates of treatment.

School Attendance

Is your child currently attending school (remote or in person?) Has your child ever struggled to attend school consistently?

Anxiety

What are the ways that your child’s anxiety is interfering with family/parent functioning?

How did you hear about this group?

Please let us know how you learned about this group - Ross Center newsletter, website, recommendation from therapist/psychiatrist/pediatrician (please include the name), etc.

Are you or your child currently on the waitlist at The Ross Center for individual parenting work and/or individual therapy for your child?

Yes

No

Please check all the days/times below that you might be interested in attending a SPACE group:

Monday Noon

Tuesday Late Morning

Tuesday Evening

Wednesday Morning

Name

This field is for validation purposes and should be left unchanged.

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