Neuropychological assessment referral form - NSW Health



Neuropsychological Assessment Referral FormPlease provide as much detail as possible. Referral Date: ClientName:Phone Number:Date of Birth:Address: Aboriginal ? Yes ? N o Torres Strait Islander ? Yes ? No Medicare number:ReferrerName:Phone Number:Email:Reason for referral/history of cognitive problemsHIV historyDate of diagnosis:Past opportunistic infections (and dates if known):Most recent CD4 count and viral load (Provide a copy of pathology results if possible):Nadir (lowest ever) CD4 count (and date):Current medications (and how long been on):CT/MRI brain scans? (copy of report would be useful if possible)Other relevant medical historyNeurological:Psychiatric:Drug and alcohol:Co-morbid conditions (e.g. Hepatitis C):Other:Anything else you consider relevant?WH&SThe referrer should locate a suitable room for conducting the assessment. Neuropsychological assessments will not be conducted in people’s homes.Are you aware of any safety concerns in seeing this client?Will there be other staff nearby?Is the furniture in the room arranged/able to be arranged so that I can sit closest to the door?For more information contact Michelle Holmes on (02) 9382 8600. ................
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