Referral for Psychological Evaluation - Texas Health and ...



Form 3424 June 2017Division for Rehabilitation ServicesReferral for Psychological EvaluationTo (name of licensed psychologist): FORMTEXT ?????Date and time consumer is scheduled for evaluation: FORMTEXT ?????Consumer Information The information requested is necessary to help counselors determine eligibility and/or a plan for rehabilitation services for the person named. Identifying DataName: FORMTEXT ?????Birth date: FORMTEXT ?????Social Security number: FORMTEXT ?????Consumer’s phone number: ( FORMTEXT ???) FORMTEXT ?????Education: FORMTEXT ?????Speaks (enter X to select): FORMTEXT ?? English FORMTEXT ?? Spanish FORMTEXT ?? Other: FORMTEXT ?????Reads (enter X to select): FORMTEXT ?? English FORMTEXT ?? Spanish FORMTEXT ?? Other: FORMTEXT ?????Reported disability: FORMTEXT ?????Reason for referral: FORMTEXT ?????Specific accommodations required: FORMTEXT ?????Return Report To Name: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Test Batteries (Enter X in appropriate boxes): FORMTEXT ?? General diagnostic battery interview and history full scale intelligence testprojective or objective personality teststandardized academic achievement testreview and evaluation with written report including the five DSM-IV or DSM-IV-TR axes FORMTEXT ?? Learning disability diagnostic battery interview and historyfull scale intelligence testprojective or objective personality testcomprehensive standardized academic achievement test (e.g., WJ, PIAT*)review and evaluation with written report including the five DSM-IV or DSM-IV-TR axes *Note: If you cannot administer one of the comprehensive achievement tests because of the consumer’s status and a similar battery is more appropriate, document why in the evaluation report. FORMTEXT ?? Neuropsychological battery—Obtained from a licensed psychologist who has specific training and experience in administering and interpreting neuropsychological tests.diagnostic interviewreview of historyevaluation of verbal-cognitive factorsevaluation of emotional coping factorsevaluation of sensorimotor factorsstandard neuropsychological batterieswritten report with the five DSM-IV or DSM-IV-TR axes FORMTEXT ?? Deafness or hearing loss psychological battery—Obtained from a licensed psychologist who has specific training and experience in administering and interpreting deafness or hearing loss evaluations. interview and historyintelligence test*projective and/or objective personality test*standardized academic achievement test*review and evaluation with written report including the five DSM-IV or DSM-IV-TR axes*Note: Use only select testing materials determined appropriate for deaf or hard of hearing consumers. FORMTEXT ?? Other (explain): FORMTEXT ?????Generally, use the current version of psychological testing materials when completing test batteries. But you may use an earlier version if you believe that it is more appropriate. In the evaluation report, document why the earlier version is more appropriate.With a non-English-speaking and/or -reading person, use test batteries in the person’s primary language or a qualified interpreter. Focus of Evaluation Specific question(s) to be answered by the psychological evaluation: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Vocational objective(s) under consideration, if any: FORMTEXT ????? FORMTEXT ?????Additional Information Current specific disabilities reported: FORMTEXT ?????Current specific disabilities established: FORMTEXT ?????Current specific disabilities suspected: FORMTEXT ?????History of consumer includes: (Selections marked with ** require more information in the Explanatory remarks section; enter X to select all that apply). FORMTEXT ?? Accident proneness FORMTEXT ?? Irregular discharge from the armed services** FORMTEXT ?? Attempted suicide** FORMTEXT ?? Misconduct in school** FORMTEXT ?? Brain damage or other neurological disorder** FORMTEXT ?? Neurotic behavior** FORMTEXT ?? Broken home FORMTEXT ?? Physical disability** FORMTEXT ?? Chronic employment instability FORMTEXT ?? Placement in special education classes or school for exceptional children** FORMTEXT ?? Chronic or acute familial discord** FORMTEXT ?? Prostitution FORMTEXT ?? Chronic school failure FORMTEXT ?? Psychotic behavior** FORMTEXT ?? Criminal behavior** FORMTEXT ?? Receipt of psychotherapy** FORMTEXT ?? Difficulty with mood or anxiety** FORMTEXT ?? Receipt of public assistance FORMTEXT ?? Divorce or separation FORMTEXT ?? Receipt of Social Security benefits** FORMTEXT ?? Drug or alcohol abuse or addiction** FORMTEXT ?? Sexual deviation** FORMTEXT ?? Hallucinations or delusional thinking** FORMTEXT ?? Hospitalization for psychiatric disorder** FORMTEXT ?? Other (describe): FORMTEXT ?????Factors that might affect testing (suspected or established): FORMTEXT ?? Illiteracy** FORMTEXT ?? Impaired vision** FORMTEXT ?? Impaired hearing** FORMTEXT ?? Ethnic or cultural** FORMTEXT ?? Fear of testing** FORMTEXT ?? Medication effects** FORMTEXT ?? Resentment of testing** FORMTEXT ?? Other (describe): FORMTEXT ?????**Explanatory remarks: FORMTEXT ?????Attachments Enter X to select all that apply. FORMTEXT ?? Initial case notes FORMTEXT ?? Medical records FORMTEXT ?? School records FORMTEXT ?? Social history FORMTEXT ?? Court records FORMTEXT ?? Vocational Communication Assessment for Hearing Impaired Consumers FORMTEXT ?? Previous psychological evaluation FORMTEXT ?? Other (describe): FORMTEXT ????? ................
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