Psychological Evaluation Referral Form

Appointments/Questions

If you have questions regarding a referral or scheduling, please contact Kim Barnes.

Telephone: (336) 265-7114
Email: kbarnes@itherapy.com

Date

Client Information

First name

Last name

Prefer to be Called

Gender

Male Female Other

(Please Specify)

Other

Home phone number

Cell phone number

Email address

Date of birth

Age

Street Address

City

State

Zip Code

Please Indicate if Previous Psychological Testing Has Been Completed

Yes No

If yes, please indicated below date and type of testing below.

Month/Year of Testing

Contact Person (if other that client)

First name

Last name

Relation to Client

Home phone number

Cell phone number

Email address

Referral Source

Name

Agency/Organization

Phone Number

Fax Number

Reason for Referral

Presenting Problem, Symptoms, Needs, etc.

Specific Testing Requested

Please list

Other Information

Please list any additional information you like to provide.

Insurance/Funding Source

Primary Insurance

Primary Insurance We do not accept Medicare and Tricare at this time.

Blue Cross Blue Shield CIGNA Medcost Self Pay Medicaid

If Medicaid, please indicate entity below.

If Medicaid:

Partners Vaya Carolina Access/Health Choice

Primary Insurance Member Number

Secondary Insurance

Blue Cross Blue Shield CIGNA Medcost Medicaid

If Medicaid:

Partners Vaya Carolina Access/Health Choice

Secondary Insurance Member Number

If No Insurance Coverage

Please indicate alternate funding source.

Please indicate any additional information such as specific date requests, etc.

File Attachments

Background Information Please attach any CCAs, Intake Forms, Previous Evaluations & Psychological Testing Results or Other Information that may be helpful.

Add file

Please upload a file

Your information will be encrypted.

Clearview Testing Centers/Carol Pulley L.P.A.

Carol Pulley, LPA - I am a licensed psychological associate who specializes in psychological and psychoeducational testing. I conduct psychological assessments for learning disorders, ADHD, autism, personality functioning, depression, anxiety, and diagnostic clarification. A comprehensive assessment includes an evaluation of cognitive/intellectual functioning, academic achievement, executive functioning, attention/concentration, learning and memory, social/emotional development, and personality. I bring warmth, humor, and compassion to the testing process.