Referral for Psychological Evaluation

After completion of this form, an estimate of costs for the evaluation will be prepared and shared with party responsible for payment. This estimate is based on the information provided at the time of referral. Changes to the referral question(s), additional records provided for review, or testing performed will impact the final fee. All records required for completion of the evaluation must be received prior to scheduling evaluation. Fifty percent of estimate is due no later than the date of the first testing session with the remaining balance (adjusted for actual time spent) due prior to the release of the report.

Date

Evaluee Information- Who is being evaluated?

Name of Evaluee

Phone Number

Permission to leave voice mail?

Yes No

Address

Date of Birth

Payor Information-Who is responsible for payment?

Person/agency responsible for payment (If self-referred, client or guardian information)

Billing Address

Phone#

Permission to leave voice mail?

Yes No

Email address

Legal information

Is this evaluation court-ordered?

Skip to referral source

Yes

complete court-information; copy of court order must be received before court-ordered services can be scheduled

Name of Court Contact Person

Contact Phone #

Name of Court

Specify county, city, etc.

Name and address where evaluation is to be sent

Will parties stipulate to the evaluation report or will testimony be required?

Testimony requested/required Parties will stipulate to the report Unknown at this time

Client's attorney (if relevant)

Client's attorney Phone #

Client's attorney email

Referral Source- Who is requesting the evaluation?

Referring agency/individual (if applicable)

If requesting evaluations for yourself, indicate "self"

Contact person

Relationship to client (attorney, case worker, parent, etc)

Contact phone #

Contact email

Name and address where evaluation should be sent (with appropriate consent)

Focus of Evaluation- What are the circumstances and questions surrounding this request for evaluation?

What prompted this evaluation?

Has this person made threats to kill others?

Yes No

Has this person made ever attempted to kill or seriously harm others?

Yes No

Has this person made threats to kill or harm themselves?

Yes No

Has this person ever attempted to kill or harm themselves?

Yes No

Does this person have a previous medical or psychiatric diagnosis?

Yes No

If yes, please list:

Referral for Psychological Evaluation

Carla Sloan-Brown, LCP

Licensed Clinical Psychotherapist