Testing/Evaluation/Psychiatry Referral Form

Psychiatry / Testing / Evaluation Referral Form

to be completed by referring CBI clinician
Patient ID*
Date of Referral*

MonthDayYear
Date
Referring Provider Name:*
Your Relationship to Patient*

PsychiatristTherapistOther
Email*
example@example.com
Non-licensed providers:

*Please review referral with supervisor prior to completing; your supervisior may be contacted regarding referrals received as needed.
Supervisor Name/Credentials (if applicable)
Patient's primary DSM-V diagnosis / diagnoses:*
Reason for Referral:*

Psychiatric Evaluation to begin medication managementComplexity Evaluation for diagnostic clarificationFull Psychological TestingOther
Complexity Evaluation Services - CBI is now offering comprehensive diagnostic evaluations for clients!

Clients at Cognitive Behavior Institute can see one of these specialized providers for a one-time comprehensive evaluation as an alternative to psychological testing services, as testing is a HIGHLY specialized service (last resort) and not always needed for diagnostic clarity.

These evaluations are being offered to help support access and reduce wait times for testing/evaluation services. Evaluations are currently being conducted in-person at the Cranberry Twp office location.
Reason seeking full psychological testing:*

Needed/Requested for ongoing medication managementNeeded/Requested for work or educational accomodationsLack of progress in treatment (therapy or medication response)Concerns related to cognitive functioning, social functioning, learning/development, etc.Other
Please provide additional information/rationale for your referral:*
Screening Questions
Does this patient have any past/active psychosis or mania concerns?*

NoYes
IF YES: please note that CBI's psychiatric staff is not able to accept any clients with active psychosis or mania concerns, and the client would need to be referred outside of CBI to a provider who can provide in-person psychiatric care.
Does this patient have any alcohol and/or substance abuse concerns?*

NoYes, present abuseYes, in the past
IF YES: active substance abuse impacts the validity of psychological testing, and testing will not be scheduled by CBI if this is indicated.
Is this patient currently using medical marijuana?*

No, never usedYes, present use for non-medical reasonsYes, present use for medical reasonsPast use only
IF YES: use of marijuana (medical or recreational) impacts the validity of psychological testing and therefore it is not recommended if used regularly.
Does the patient have a current diagnosis or hisotry of an eating disorder?*

NoYes current diagnosisYes, past history (within the last year)Yes, past history (1-2 years)Yes, past history (more than 2 years ago)
Has this patient had previous psychological testing?*

NoYes
Has this patient had previous psychological testing in the past 12 months?*

NoYes
IF YES: a copy of past psychological testing must be provided to CBI prior to scheduling.
Are there any relevant medical issues for this patient?*

NoYes
Please describe:
Is this patient currently under your care for medication management to treat psychiatric symptoms that may impact psychological testing results (i.e., stimulants, sedatives)?*

NoYes
IF YES: In making this referral, I agree to coordinate a plan with my patient prior
to psychological testing services. The validity of testing results can be impacted
while my patient is taking these medications and I agree to discussion of this with
my patient prior to testing services.
Are you considering a higher level of care for this patient?*

NoYes
IF YES: This should be pursued first.
If testing is needed to support determination of need, please describe below.
Are there any safety-related concerns for this patient?*

NoYes
IF YES: Safety-related concerns should be considered primary prior to psychiatry/testing/evaluation services.
Is the patient currently involved with the judicial/court system or have pending or ongoing legal proceedings?*

NoYes
Current Med List (if applicable):
Clinician Signature

Powered by Jotform SignClear
Should be Empty:

Psychiatry / Testing / Evaluation Referral Form

Screening Questions