External Psychological Testing Referral

Psychological Testing Referral

to be completed by referring clinician
Patient Name*
Date of Birth*

MonthDayYear
Date
Date of Referral*

MonthDayYear
Date
Referring Provider Name:*
License Number:*
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Your relationship to the patient:

Current general medical care provider (primary care)Current mental health provider (therapist, psychiatrist, etc.)Other
Non-licensed providers:

*Please review referral with supervisor prior to completiong; your supervisior may be contacted regarding referrals received as needed.
Supervisor Name/Credentials
Patient's current DSM-V diagnosis:*
Clinical Reasons for Psychological Testing (select all that apply):*

Diagnostic clarificationLack of progress in treatment (therapy or medication response)Requested as consultation for medication management purposesRequired for continued medication managementCognitive functioning concerns (memory, attention, overall abilities/IQ)Learning/developmental functioning concerns (delay indicated)Social functioning concerns (social skills, relationships)Emotional functioning concerns (mood, regulation)Personality functioning concerns (personality-related disorders)Court-ordered/court-related evaluation neededWork or educational accommodations neededPatient requested referral for testing
Rationale for psychological testing (required for insurance purposes):*
Screening Questions
Does this patient have any current substance abuse concerns?*

NoYes
IF YES: active substance abuse impacts the validity of psychological testing, and testing will not be scheduled by CBI if this is indicated.
Is this patient currently using medical marijuana?*

NoYes
IF YES: use of marijuana (medical or recreational) impacts the validity of psychological testing and therefore it is not recommended if used regularly.
Has this patient had previous psychological testing?*

NoYes
Has this patient had previous psychological testing in the past 12 months?*

NoYes
IF YES: a copy of past psychological testing must be provided to CBI prior to scheduling.
Are there any relevant medical issues for this patient?*

NoYes
Please describe:
Is this patient currently under your care for medication management to treat psychiatric symptoms that may impact psychological testing results (i.e., stimulants, sedatives)?*

NoYes
IF YES: In making this referral, I agree to coordinate a plan with my patient prior
to psychological testing services. The validity of testing results can be impacted
while my patient is taking these medications and I agree to discussion of this with
my patient prior to testing services.
Are you considering a higher level of care for this patient?*

NoYes
IF YES: This should be pursued first.
If testing is needed to support determination of need, please describe below.
Are there any safety-related concerns for this patient?*

NoYes
IF YES: Safety-related concerns should be considered primary prior to psychological
testing services. Testing will not be scheduled by CBI if indicated.
Clinician Signature

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Psychological Testing Referral

Screening Questions