Pediatric Neuropsychological Testing Referral Form

Please complete the form as best you can. You will receive a call or email in 3 business days to verify referral and obtain further information before scheduling. Please anticipate 3-5 weeks for an appointment.

For all insurance coverage, we will need a referral from a primary care provider or medical specialist to verify that the evaluation is medically necessary.

The referral questions are important as we need to make sure neuropsychological testing is the appropriate service. Neuropsychological testing assesses brain function based on known performance profiles. Neuropsychologists are trained in clinical psychology, neurology, neuroanatomy and psychometrics (testing).

Note that insurers will not cover evaluations for ADHD-ADD, learning disabilities or diagnostic evaluations for Pervasive Developmental Disorders. We are happy to do these evaluations if supported. Schools can recover up to 50% of the cost of independent evaluations for children with Medicaid.

Please fax relevant treatment or evaluation records, including school testing, MRI reports, and EEG reports prior to the evaluation.

Entries marked with * are required.

General Information
Child/Student's First Name*:
Child/Student's Last Name*:
Age*:
Date of Birth*:	Calendar
Gender*:	Female Male
School:
Grade:
Who is completing this form*:
What is your relationship to the child/student:
Your phone or email*:
Name of Parent*:
Guardian (if different than above):
Parent/Guardian Contact (phone or email)*:
Referral Information
Referring M.D. name*:
What is the problem? How does this impact the child*:
What is the referral question? What would you like to learn*:
Are you requesting a specific clinician or a staff pediatric neuropsychologist:
Clinical Information
Is there a current diagnosis? (list):
Has the child been a patient at DHPA before:	Yes No
Has the child had neuropsych. testing before:	Yes No
Does the child have a 504 plan or IEP at school:	Yes No
Pediatrician's name:
Other medical or mental health professionals currently involved in the child's care:
Payment Information
How will this eval. be paid for:
Insurance Provider:
Subscriber:
Certificate #:
Group: