Please Type All Information, If Possible. Thank You

Please type all information, if possible. Thank you.

Please email to

Person submitting this referral: __ Email address: ___

Thank you in advance, Eneida M. Silva, Ph.D. / Neuropsychologist - (NPI: 1477800837)

Please fill out all fields below -- if it doesn’t apply, please write NA.

Name:

Date of Birth:

Age:

Phone number for patient:

Email address for patient:

Address:

Language spoken by patient:

Language spoken by patient’s parent / foster parent / caretaker:

Parent’s Name:

School and Teacher (if child):

Primary Insurance: ID- Group #:

Phone for insurance:

Secondary Insurance: ID- Group #:

Phone for insurance:

Date:

1.  Current Symptoms and Duration of Symptoms:

2.  If patient is a child, is he or she capable of engaging in the evaluation without becoming significantly aggressive? Also, do you feel he or she will be cooperative and fully participate in the evaluation? If you feel the answer is no to both questions, please be aware that the evaluation would probably not be successful, since results would not be valid, and probably should not proceed at this time.

Yes ____ No____

If No, please explain below:

3.  Is child verbal (able to express him/herself orally via language)?

___Yes ____No (if no, please explain)

4. Referral Questions and why is testing being requested at this time?

1.

2.

3.

5. Has patient been evaluated by a psychiatrist?

If yes, when?

6. If know, current medications being taken for a psychological condition? (for example, Zoloft, Ativan, etc.)

7. If known, current working diagnoses being considered (DSM-V):

8. History of patient - Psychosocial and medical information (with examination dates) and previous treatment. Include any past psychological testing, date and results, medical, psychiatric and neurological exam, if available:

9. How will proposed testing enhance treatment and impact future treatment?

9. Is patient currently in treatment? Yes____ No_____

If Yes, specify modality: individual ______group ______family ______

Name of provider: ______

10. If known, are there medical explanations other than psychological ones that could explain current behaviors or symptoms? For example, thyroid dysfunction, closed head injury, medications, poisoning, etc.)

Yes _____ No ______

If Yes, please describe:

11. Main reason for evaluation:

For example: The evaluation will provide clarity regarding individual’s neuropsychological functioning with respect to any physiological and cognitive deficits regarding the way information is processed and how this impacts ability to process emotions and engage with others interpersonally and behaviorally. It will also significantly help determine best treatment plan and options for this individual.

The main reason for seeking this evaluation is as follows:

12. Referrals Questions:

Please write down 3 or 4 referral questions you would like answered by the evaluation:

Example -- What is the most effective way for him/her to learn new information?

1.

2.

3.

4.

Submitted by: ______Email address: ______

Please email to

Thank you, Dr. Eneida Silva