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Neuropsychological TestingReferral InformationChild Form**Accepting FULL MaineCare, or BCBS Insurance Only**Neuropsychology Department email: neuro@ 197485381000Date:Referred by:DOA:OCS #:Child’s Name:D.O.B.:Age:Gender:Grade:Parent/Guardians: Guardian address: Guardian Contacts: OK for FORMCHECKBOX Phone:communication? FORMCHECKBOX Cell: FORMCHECKBOX FORMCHECKBOX Email: FORMCHECKBOX Check preferred method of contactPatient Insurance: FORMCHECKBOX Mainecare FORMCHECKBOX BCBS ID No:Primary Care PhysicianName:Phone:Fax:Psychiatrist:Name:Phone:Fax:Counselor/ Therapist:Name:Phone:Fax:Caseworker/ Case Mgr:Name:Type:Phone:Fax:Other Professional:Name:Type:Phone:Fax:School:Name: FORMCHECKBOX Homeschooled District:Current Diagnoses:Current Medications:Current ServicesCheck all that apply FORMCHECKBOX School IEP/Special Ed FORMCHECKBOX School 504 Accommodations FORMCHECKBOX School Counselor FORMCHECKBOX Tutoring FORMCHECKBOX Occupational Therapy FORMCHECKBOX Speech Therapy FORMCHECKBOX Physical Therapy FORMCHECKBOX Vision Therapy FORMCHECKBOX Naturopathy FORMCHECKBOX HCT FORMCHECKBOX BHP FORMCHECKBOX VRT FORMCHECKBOX MST FORMCHECKBOX Psychotherapy FORMCHECKBOX Behavior Therapy (e.g., ABA) FORMCHECKBOX Group Therapy FORMCHECKBOX Social Skills training FORMCHECKBOX Other- Describe: Current Status Check all that apply FORMCHECKBOX DHHS Involvement FORMCHECKBOX Foster Care FORMCHECKBOX Adoption Process FORMCHECKBOX Incarcerated FORMCHECKBOX JSOP/Probation Supervision FORMCHECKBOX Other: Reason for ReferralCurrent concerns/ Identified Issues / Duration of problems / Progress in treatmentCognitive Concerns Check all that apply FORMCHECKBOX General Intellectual Abilities FORMCHECKBOX Attention / Concentration FORMCHECKBOX Academic Skills / Learning disabilities FORMCHECKBOX Memory / Learning FORMCHECKBOX Language / Communication FORMCHECKBOX Visual Spatial Processing FORMCHECKBOX Sensory Processing FORMCHECKBOX Motor Functioning FORMCHECKBOX Auditory / Phonological Processing FORMCHECKBOX Social Cognition FORMCHECKBOX Reasoning / Problem solving FORMCHECKBOX Judgment / Decision making FORMCHECKBOX Executive Processing (sequencing, FORMCHECKBOX Other cognitive concerns shifting between tasks, working memory, Describe: processing speed, multi-tasking, etc.)Other Concerns Check all that apply FORMCHECKBOX Traumatic brain injury / concussion FORMCHECKBOX Substance Abuse in pregnancy FORMCHECKBOX Birth Injury FORMCHECKBOX Autism characteristics FORMCHECKBOX Anxiety FORMCHECKBOX Moodiness / Emotional dysregulation FORMCHECKBOX Depression FORMCHECKBOX Obsessive or compulsive behaviors FORMCHECKBOX Anger FORMCHECKBOX Oppositionality / Defiance FORMCHECKBOX Poor social skills / no friends FORMCHECKBOX Sexual misbehavior FORMCHECKBOX Other concerns- Describe:Person ReferringName:Relation: FORMCHECKBOX Phone: FORMCHECKBOX Cell: FORMCHECKBOX Email:Check preferred method of contactCancellation List FORMCHECKBOX Should be placed on a list for an earlier appointment if we have a cancellation.Please send any available documentation of the referral for Neuropsychological Testing and the most recent medical examination, as well as any relevant records: brain scans, EEG reports, Psychological or Neuropsychological reports, OT, PT, or SLP evaluations, school 504 plan or IEP, or DHHS or legal recordsOffice Use FORMCHECKBOX Approved FORMCHECKBOX Not within guidelines. Reason:Initials: FORMCHECKBOX Insurance Confirmed FORMCHECKBOX Registration/LHQ sent: Initials: Revised: 2020 ................
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