Referral Form

Client Referral Form
REFERRAL FORM is needed PRIOR to scheduling.

Please fill out the requested information below, and click "submit" to submit the form. You will be prompted to e-sign and be given the opportunity to download the form as a PDF. You must carefully read the e-sign document to ensure all information is correct and any additional information is understood. It will be emailed to you as well.

If you prefer to print out and mail/email/fax in your paperwork, this form is available in PDF format on our website www.GECtesting.com

*We do not currently accept Medicare, Wellcare (despite transition to CCH), Anthem BCBS, or United Health Care (commercial plans). If you're unsure about our ability to take your insurance, please contact us at info@gectesting.com
Which of our locations are you interested in being seen at?
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date Of Birth
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Can we text you?
Can we leave you a voicemail?
Gender

Other
Parent / Legal Guardian (If Applicable)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Agent
Agent Name
Referral Agency
Email
example@example.com
Relationship to Client
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Send Completed Report By:
Telehealth Services

In order to provide effective telehealth services, the person being assessed must be over the age of 16 and able to engage meaningfully while unsupervised. Leave this section blank if the patient is under age 16.
Are you interested in completing your assessment via telehealth?
If yes, do you have access to the following?
DSS Involvement
Is DSS Involved
If DSS involved, please provide social worker's information
Insurance Information

Check All That Apply
BOTH MEDICAID AND OTHER INSURANCE MUST BE LISTED, IF APPLICABLE. We do not accept only Medicare. If you have Medicare and secondary coverage, please call the office to confirm coverage for testing.
MEDICAID

Other
If Other Medicaid, Please List
COMMERCIAL PLAN *We do not currently take United Healthcare*

Other
If Other Commercial Plan, Please List
INSURANCE ID NUMBER
Please upload the front and back of your insurance ID Card if available:

Cancelof
Please upload the front and back of your insurance ID Card:

Cancelof
Client's Current Diagnosis
Prescribing Doctor
Current Medication(s)
Prescribing Doctor's Office Number
Is This Assessment Court Ordered?
Medical Necessity

In order for insurances to reimburse providers for Psychological Testing, the testing must be Medically Necessary. Medical Necessity is defined as a service which, in the opinion of the primary service provider, is reasonably needed to prevent the worsening of a condition, to establish a diagnosis and/or to assist the covered individual to achieve maximum functional capacity. PLEASE CLEARLY DEFINE THE MEDICALLY NECESSARY REASONS FOR THIS INDIVIDUAL TO RECEIVE TESTING. Please list current symptoms and thier impact ot work, school, and/or social functioning. Additionally, please list goals for this assessment.
Information below must be provided to determine eligibility for testing prior to scheduling:
Testing Type
• Behavioral-Emotional/Developmental/Cognitive: Psychological assessment to assist with diagnostic clarification, assess current level of functioning and make recommendations for services and/or treatment if appropriate

• Eligibility Determination: Determination of eligibility for placement based on testing outcome.

• IDD Services: Required testing for IDD services

• Educational Testing: Please note insurances do not pay for academic testing.
Please check all that apply
Current Services (Please check all that apply)
Provider(s)
History: Please check all that apply (*Copies of prior assessments are helpful if available)
Name of Person signing this form

First NameLast Name
Signature
Should be Empty:

Client Referral Form

Client Information

Parent / Legal Guardian (If Applicable)

Referral Agent

Telehealth Services

DSS Involvement

Insurance Information

Testing Type