All clients seeking psychological testing services should review the information on our website prior to completing this form.
REQUIRED: Please have your referring provider or current mental health provider complete the form at the link below in order to proceed with psychological testing services. The first link is to a fillable electronic form while the second is a link to a PDF version of the form.
Electronic Psych Testing Provider Referral Form (or copy this link: https://hipaa.jotform.com/223486018038153)
PDF Psychological Testing Provider Referral Form
This form is required. Testing intakes will be scheduled once completed form is received.
The completed form can be sent back to CBI via email firstname.lastname@example.org or via fax #724-299-8964.
IMPORTANT:Unfortuantely, CBI is not in network with any Medicaid or State-funded insurance products at this time. Therefore, we will not be able to proceed with scheduling a new patient appointment at this time.
If you would like a list of referrals or have additional questions, please contact our office directly 724-609-5002 or send us an email: email@example.com
The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months.
"Drug abuse" refers to (1) the use of prescribed or over‐the‐counter drugs in excess of the directions, and (2) any nonmedical use of drugs.
The various classes of drugs may include cannabis (marijuana, hashish), solvents (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages.
Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.
Drug Abuse Screening Test (DAST‐10). (Copyright 1982 by the Addiction Research Foundation.)