Child or Adult Neuropsychological
Provider Referral Form
Client Demographics
Name
*
First Name
Last Name
Date of Birth
*
MM/DD/YY
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Referring Provider Demographics
Name
*
Provider name
Telephone Number
*
phone number with extension
Fax Number
*
fax number with area code
Email
*
example@example.com
Is there an active release on file? If so, please send to (888)991-2741 or attach below
Yes
No
Attach Release of Information and records below
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REFERAL QUESTION: What do you hope this evaluation will clarify? What is your main concern as a provider for this client?
THE FOLLOWING MUST BE COMPLETED:
Neuropsychological assessment is a specialized clinical assessment of the recipient’s underlying cognitive abilities related to thinking, reasoning and judgment. Please note your concerns in the space below:
A brain disorder is known or strongly suspected to exist because of the patient’s medical history or a neurological evaluation and includes the following:
Brain disorder resulting from past significant head trauma (TBI) A significant behavioral change, memory loss or other organic brain injury
Brain tumor
Stroke, Neoplasms or vascular injury of the central nervous system
Seizure disorder
Brain disorder resulting from significant exposure to neurotoxins, Exposure to systemic or intrathecal agents or cranial radiation known to be associated with cerebral dysfunction, Central nervous system infection or other infectious disease
Fetal alcohol syndrome
Cerebral anoxic or hypoxic episode (including birth anoxia and cord concerns)
Neurodegenerative disorder, Demyelinating disease, Extrapyramidal disease
Systemic medical condition known to be associated with cerebral dysfunction, including renal disease, hepatic encephalopathies, cardiac anomalies, sickle cell disease and related hematologic anomalies, and autoimmune disorders such as lupus erythematosus or celiac disease
Congenital, genetic, or metabolic disorder known to be associated with cerebral dysfunction, such as phenylketonuria, craniofacial syndromes or congenital hydrocephalus
Severe or prolonged malnutrition or malabsorption syndrome
Dementia or vascular concerns
Suspected neuropsychological impairment in addition to functional psychopathology such as substance abuse or dependence
Cognitive or behavioral symptoms suggest the recipient has an organic condition that cannot be readily attributed to functional psychopathology including the following:
Poor memory or impaired problem solving
Change in mental status evidenced by lethargy, confusion or disorientation, A significant mental status change that is not a result of a metabolic disorder and has failed to respond to treatment
Deterioration in level of functioning, Marked behavioral or personality change
In children or adolescents, significant delays in acquiring academic skill or poor attention relative to peers
In children or adolescents, significant plateau in expected development of cognitive, social, emotional or physical function relative to peers
In children or adolescents, significant inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional or physical demands.
Condition presenting in a manner making it difficult for a clinician to distinguish between the following:
Neurocognitive effects of a neurogenic syndrome (such as dementia or encephalopathy) andMajor depressive disorder when adequate treatment has not resulted in improvement in neurocognitive functioning, or another disorder (for example, autism, selective mutism, anxiety disorder, or reactive attachment disorder)
ADHD vs other disorder
Current level of functioning
General Ability and functioning levels
Determine the status of the clients emotional, intellectual, and emotional functioning
Second Opinion
Referring Provider Signature
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