CReATE Professional Referral Form (Child/Adolescent)

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CReATE Professional Referral Form (Child/Adolescent)

Please tell us a little more about the child so we can better understand their needs for testing. If you have difficulties with this form, please call our office at 828-231-3297

The information submitted in this form is guaranteed to be kept confidential and secure. Please wait for the confirmation page to appear once you submit your form.
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General Child Information
Child's Name (First & Last)
Preferred Name
Child's Date of Birth
Please Select
Please Select
Male
Female
Other
Biological Sex/Gender
Current Grade
Please Select
Please Select
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3
4
5
6
7
8
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10
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Child's Age
Current School
Please Select
Please Select
English
Spanish
Russian
Chinese
French
Arabic
Other
Primary Language
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Please tell us about the child's biological sex and preferred gender :
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Parent/Guardian Information
Name of parent or guardian
Please Select
Please Select
Biological Parent
Adoptive Parent
Step Parent
Foster Parent
Grandparent
Guardian
Other
Relation to child/adolescent
Email address
Phone Number
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Referring Professional
Your Name
Your Position or Specialty
Your Practice, Program, or School
Please Select
Please Select
Yes
No, please just send report
Would you like to speak with us?
Please enter your phone
Please enter your email
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Child lives with :
Both Parents
Only One Parent
Two Separate Households
Single Parent
Foster/Legal Guardian
Other
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Are you aware of any legal action underway with the family? (e.g. custody, adoption, termination of parental rights, civil suit, etc.) * This field is required.
YESNO
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Please explain the legal action that is currently underway. 
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Briefly describe the reason for referral, concerns, or a little about the child/adolescent's current difficulties:
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What would you (and/or the parents) like to learn from this evaluation?
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Have you discussed your reasons for referral with the parents/guardian?
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Referral Information
Please Select
Please Select
Yes
No
Are you referring to a specific psychologist?
If yes, please the name of the psychologist.
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Type of evaluation:* This field is required.Please check one or all that apply:
Comprehensive Psychoeducational Evaluation: A comprehensive psychoeducational evaluation is a comprehensive and thorough evaluation that includes assessment of underlying cognitive, processing, learning, attentional, and academic abilities to better understand a child’s strengths and challenges and answer questions regarding possible cognitive disabilities, ADHD, or learning disabilities. This is a comprehensive evaluation that is typically sufficient for learning or attentional difficulties in school.
Add on Neuropsychological Testing - A few neuropsychological tests are a part of our comprehensive psychoeducational evaluation but not an in-depth evaluation of all domains. Some complex presentations require neuropsych testing (e.g., fetal alcohol exposure, seizure disorder, etc.). Other times, parents and/or educators may want the most in depth understanding of the child’s skills and abilities that are linked to brain functioning. For example, this includes additional assessment in the areas of language, attention, executive functioning, learning and memory, visual spatial, and/or fine motor, depending on the needs of the child (Neuropsychological Evaluation)
Add on Psychological Testing – A broad or general assessment of socioemotional and behavioral domains is included in the psychoeducational or neuropsychological evaluation but not an in-depth evaluation of these domains. Add on Psychological testing if mental health, socioemotional, or behavioral health concerns are prominent (e.g., trauma/attachment, OCD, mood, anxiety, Autism spectrum, etc.) (Psychological Evaluation)
Add on Autism Spectrum Disorder (ASD) Testing
Not sure if Psychological or Neuropsychological Testing are needed – Please Advise.
Developmental - Ages 5 and under only
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Areas of concern :* This field is required.(check all that apply)
Dyslexia or reading concerns
Dyscalculia or math concerns
Dysgraphia or writing concerns
General learning/processing concerns
ADD/ADHD or attentional concerns
Autism Spectrum concerns
Language concerns (receptive, expressive)
Behavioral concerns
Social concerns
Emotional concerns
General developmental concerns
Trauma or stressors
None
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Areas of concern :* This field is required.(check all that apply)
Anxiety or Mood concerns
Traumatic Brain Injury (TBI) and Concussion effects
Brain tumor or cancer effects
Epilepsy/Seizure Disorder effects
Other Brain related concerns
Fetal Alcohol Effects
Mental health concerns (or psychiatric)
Substance abuse concerns
Obsessive-Compulsive concerns
Personality or clinical concerns
Thought or psychosis concerns
None
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Please let us know if there is anything else we should know or be aware of in working with this child/adolescent and/or their family.
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Do you have records to send us? This may include a copy of your assessment, medical records, school records, mental health records, application for the client/patient to attend your program, prior testing, etc.) Please upload any previous psychological/psych-educational testing that would be relevant to the client's assessment at CReATE by clicking the "Browse Files" button below, and selecting the file from your computer (if not applicable, please skip):
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Thank you for completing this form. The information submitted is guaranteed to be kept confidential and secure.
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