CReATE Professional Referral Form (Adult)

CReATE Professional Referral Form (Adult)

Please tell us a little more about the client 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.

General Client Information

Client's Name (First & Last)

Preferred Name

Client's Date of Birth

Biological Sex/Gender

Client's Age

Occupation or Student

Client's email

Client's phone

Please tell us about the client's biological sex and preferred gender :

Support Person Information If we need to contact someone else on behalf of the client (e.g. spouse, parent, caregiver) please list the contact information for that individual below.

Name of support person or N/A

Relation to client

Support person's email address

Support person's phone number

Referring Professional

Your Name

Your Position or Specialty

Your Practice, Program, or School

Would you like to speak with us?

Please enter your phone

Please enter your email

Are you aware of any legal action underway with the client, or the client's family? (e.g. civil suit, legal guardianship, criminal charges, custody, etc.) * This field is required.

YESNO

Please explain the legal action that is currently underway. 

Briefly describe the reason for referral, concerns, or a little about the client's current difficulties:

What would you (and/or the client) like to learn from this evaluation?

Were any of these concerns/difficulties the result of a known event/injury (e.g., brain injury, seizure, illness etc.)?

YESNO

If Known Event, please check all that apply:

Brain Injury (TBI)

Stroke

Brain Aneurysm

Seizures

Brain or Spinal Tumor

Trauma/Stressor/Transition

Concussion with loss of consciousness

Substance Use/Overdose

Concussion without loss of consciousness

Psychiatric event (e.g. hospitalization)

Major Illness (cancer, lupus, MS, etc.)

Other

Do you have concerns regarding recent heavy substance use? (Alcohol or other substances?)

Is the client/patient in school or planning to return to school?

Have you discussed your reasons for referral with the client (or support person?)

Referral Information

Are you referring to a specific psychologist?

If yes, please the name of the psychologist.

Type of evaluation:* This field is required.Please check one or all that apply:

Comprehensive Psychological Evaluation

Comprehensive Neuropsychological Evaluation

Learning Disability or ADHD Evaluation

Autism Spectrum Disorder (ASD) Evaluation

Not sure - Please recommend

Areas of concern :* This field is required.(check all that apply)

ADD/ADHD or attentional concerns

Autism Spectrum concerns

Anxiety or Mood concerns

Mental health concerns (or psychiatric)

Personality or Clinical concerns

Substance use concerns

Dyslexia or reading concerns

Dyscalculia or math concerns

Dysgraphia or writing concerns

General learning/processing concerns

Behavioral concerns

None

Areas of concern :* This field is required.(check all that apply)

Traumatic Brain Injury (TBI)

Epilepsy/Seizure Disorder effects

Concussion with loss of consciousness

Brain Aneurysm

Concussion without loss of consciousness

Brain or spinal tumor

Major illness (cancer, lupus, MS, etc.)

Fetal Alcohol Effects

Other Brain related concerns

None

Please let us know if there is anything else we should know or be aware of in working with this client and/or their family.

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 records by clicking the "Browse Files" button below and selecting the file from your computer (if not applicable, please skip):

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Max. file size: 10.6MB

Thank you for completing this form. The information submitted is guaranteed to be kept confidential and secure.