HOPE HAVEN PSYCHOLOGICAL RESOURCE, LLC
5610 Crawfordsville Road, Suite 701
Indianapolis, Indiana 46224-3739
Phone: (317) 241-HOPE 4674 Fax: (317) 241-0201
www.hopehavenpsych.org
Psychological Testing Referral Form
Client’s Name Date of Birth Age
Guardian’s Name (if client is under 18) Address
Apt#/Suites/Lot City/State Zip Code Phone Number
Referred by or at the suggestion of
Referral Party’s Contact Information and Agency Affiliation (phone and email)
Primary Care Physician or Pediatrician When was this client’s last medical examination?
# of Yrs. in School Highest Grade Completed
Please Explain Why You Would Like this client to receive psychological testing?
What questions would you like answered from this evaluation?
How do you hope testing will benefit treatment planning and services rendered to this client?
Previous Outpatient/Home-based Mental Health Care
Year Services began/ended, Name of Provider, Previous Diagnosis, Reason services began
Previous Inpatient/Hospitalization or Intensive Outpatient Mental Health Services
Year Services were received, Length of Time in Treatment, Name of Hospital, Previous Diagnosis, Reason for admission
Current/Past Medications, Significant Medical History, Developmental Challenges, Head Injuries or Seizures
Does this client have any family history of mental health or substance abuse concerns?
Has (did) this client receive special education services in school?
If yes, what is (was) this client’s eligibility-type for special education services
Has this client ever made mention of suicide, homicide, or engaged in self-injurious behavior?
If yes, please share specifics
Please share any experience(s) this client has had with physical, sexual, emotional abuse, neglect or trauma
Provisional DSM-IV Diagnosis
Axis I
Axis II
Axis III
Axis IV
Axis V
**Rule Outs**
Has this client’s MSE been Within Normal Limits (If no, please explain)? YES NO
What are the current symptoms prompting this request for testing?
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Anxiety
Depression
Mood instability
Inattention
Hyperactivity
Eating disorder symptom
Poor academic/work performance
Withdrawal/poor social interaction
Substance Abuse
Unprovoked agitation/aggression
Self-injurious Behavior
Behavior problems (e.g., school, home, work)
Psychosis/Hallucinations
Bizarre Behavior
Personality Characteristics Other:
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If ADHD is a diagnostic rule out, please indicate results of standardized ADHD (e.g., Conners) rating scales, if available:
Positive Negative Inconclusive Not Applicable
INSURANCE
Client’s Name Client’s Birthdate
Client’s Insurance Policy Holder’s Name
Member ID Number
Client’s Relationships
To Policy Holder Policy Holder’s SSN
Name of Insurance Insurance Policy Group Carrier Number
Provider Relations/Pre-Certification
Number on Back of Insurance Card
Secondary Insurance Secondary Insurance
Carrier Number
RELEASES and CONTINUITY OF CARE
Has this client had a previous intake/bio-psycho-social assessment, or psychological/psychiatric evaluation?
YES ***If yes, please attach copies NO
I (Parent/Legal Guardian/Representative/Responsible Party) agree and consent to begin participation in psychological testing services for the above named client offered through Hope Haven Psychological Resources, LLC. By signing this agreement I am giving Hope Haven Psychological Resource permission to contact me about psychological testing services for the above named client. I am also giving Hope Haven Psychological Resource, LLC permission to check eligibility for services of the above named client.
Parent/Legal Guardian/Representative Date Parent/Legal Guardian/Representative’s Signature
Name Electronic Signature (check box)
I (the referring provider) acknowledge that I have received a signed authorization from the above named client (or guardian) to refer them for psychological testing services. I have informed the client that by authorizing this referral they are giving Hope Haven Psychological Resource, LLC permission to check eligibility for services of the above named client. I have also informed the client that they are giving Hope Haven Psychological Resource permission to contact them about psychological testing services for the above named client.
Referring Provider’s Name Date Referring Provider’s Signature
Electronic Signature (check box)
Please attach current or previous treatment plans, discharge summaries, IEPs, educational records, or pertinent information that you have available that you believe will be helpful in assessing this client.
Thank you for this referral to Hope Haven Psychological Resource
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