COUNTY OF LOS ANGELES / DEPARTMENT OF CHILDREN AND FAMILY SERVICES

REQUEST FOR PSYCHOLOGICAL TESTING REPORT

SEND TO: /

DMH CFSB

/ FAX : / (213) 487-9658
550 S. Vermont Avenue, Room 408 / (213) 736-5804
Los Angeles, CA 90020
Date of Request:
Name of Child: / DOB: / Sex:
Court Number: / Child’s Primary Language:
Case Name: / State Number:
Child’s Caregiver: / Phone Number:
Address:

REASON FOR REFERRAL: (List specific questions to be answered by the testing. Describe behavior exhibited by the child which is of concern and relevant to the questions being asked. Additional pages may be added if more space is needed.)

DMH CFSB: / Assign to practitioner selected by DMH CFSB
Assign to practitioner currently requesting authorization
Name of Practitioner:

EVALUATOR: Release report only to the child’s DCFS CSW with a copy sent to DMH CFSB

Referred by CSW (print): / Phone
Address:
File Number: / Date Report Needed By
APPROVED BY (SCSW) signature):

DCFS case records are confidential pursuant to WIC Sections 827 and 10850. The Los Angeles County Juvenile Court policy on confidentiality sets forth the details of the court’s interpretation of these statutory requirements. Failure to follow confidentiality policy may lead to disciplinary action, including discharge and civil action. Under the provisions of the statutes, a violation is a basis for criminal prosecution.

This message is intended only for the individual or entity to which it is addressed and contains information that is privileged and exempt from disclosure under applicable Federal or State law. If the reader of this message is not the intended recipient or employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at the phone number above and return this message via U.S. mail to the address for DMH CFSB given above. Thank you.

DCFS 5005 (Rev. 6/98)