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CLIENT INFOName: ______________________________________________________________________ DOB:_________________________ Contact Phone #: _______________________________ Email address: ________________________________________________City/State: ______________________________________________________ Insurance: __________________________________REFERRING PROVIDERName: ___________________________________________________ Institution: _______________________________________Contact Phone #: ___________________ Fax #: _________________ HIPAA Secure email: ________________________________CONSULTATION DETAILSPlease check Functional Neurologic Disorder (FND) symptoms:□ Psychogenic non-epileptic seizures (PNES)□ Functional motor symptoms or paralysis□ Functional speech/swallow symptoms□ Special sensory (vison, hearing, etc.)□ Other (please describe): _____________________________________________________________________________________Criteria for clients referred to the Functional Neurologic Disorder (FND) Program:□Y □N Documentation of diagnosis of FND in at least one clinical note. □Y □N Documentation of parent/patient acceptance of psychiatry referral. Diagnosing clinician name/specialty/institution (if different from referring): __________________________________________________________________________________________□Y □N Documentation in neurologic exam of “positive sign(s)” in accordance with the “incompatibility” criterion for diagnosis of FND (please see citing below for examples)□ Documentation of diagnostic workup, including EMG/NCS/MRI/CT/EEG where applicable. Note: for clients with PNES, please include specific reference to whether a typical event was captured on video EEG. For professionals: Espay AJ, Aybek S, Carson A, et al. Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA Neurol. 2018;75(9):1132-1141. Doi:10.1001/jamaneurol.2018.1264) ................
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