Psychological Evaluation Referral Request

This form is used to document the reason for referral and establish the medical necessity for psychological testing.

Many insurance plans require prior authorization before approving psychological testing. If insurance will be used for payment, the information you provide on this form will be submitted to the client’s insurance company for review. Authorization may take as little as a few days; however, processing times can be longer, particularly for clients covered by Medicaid or Medi-Cal.

Requests for psychological testing should be made only after an initial assessment has been completed. This evaluation typically includes a clinical interview, a review of relevant history, examination of prior evaluations or testing, and consultation or coordination with current and/or previous providers.

Please note that insurance does not cover testing requested solely for academic placement or forensic purposes. In addition, requests for educational testing or assessment of learning disabilities for school-related services should first be directed to the public school system. In some cases, insurance may cover a portion of the assessment costs, with any remaining balance being the client’s responsibility.

Valant Patient ID:

Which best describes the client's circumstances (check all that apply):

Which of the following have been completed (check all that apply):

Reason(s) for referral, symptoms and/or problems that necessitate testing (check all that apply):

Duration of symptoms (select one):

Briefly describe the case:

Has the client stated, “I think I have ADHD?"

Has the client stated, “I think I have Autism."

Treatment history:

Rows	Frequency	Duration of treatment	Still in treatment?	Have symptoms improved?	Comments
Individual therapy
Medication management
School/home-based
Other services

Is the client currently taking any psychotrophic medications?

If yes, please list them:

Is the client engaged in active substance use, in withdrawl, or in recovery from chronic use?

If yes, please explain.

Which rating scales have already been administered? Check all that apply.

Rating Scale Results:

Rows	Very Low	Low	Average	High	Very High	N/A
ASQ
BAI
BIS
EPDS
GAD
LDSQ
MINI
MDQ
OCD
PHQ
PCL
WURS

MINI Results (please summarize):

Diagnostic Impression(s):

Comments:

What are the client's diagnostic rule outs/ referral questions?

Has the client been tested within the past 12 months?

If yes, please provide more details (dates of testing, results etc.):

Other information that supports the medical necessity for psychological testing:

Which assessment batteries are you requesting (if known):

Client's availability for testing (check all that apply):

Completed by:

Date