Attachment 6
Riverside County Mental Health Plan
PSYCHOLOGICAL TESTING AUTHORIZATION REQUEST
__MEDI-CAL (CAT) __DPSS (ACT) __GROUP HOME (CAT)
Date of Request: _____/_____/
Consumer’s Name:
Consumer’s SS#: Date of Birth: / /
Psychologist’s Name:
Provider #: Phone #: ( ) Fax #: ( )
Psychologist’s Agency Name (if applicable):
Dates that Consumer was seen for the Assessment Sessions:
_____/_____/_____ & _____/_____/_____
After completing the Clinical Interview of the consumer, is psychological testing still required to
answer referral question(s)? __Yes __No
If the above answer was no, why not:
If psychological testing is considered the only method to answer the referral question(s), please
list tests you plan to administer:
__WAIS-R/WISCIII __Bender-Gestalt __TAT/RATC __Projective Drawings
__Rorschach __Incomplete Sentences __MMPI/MMPI-A __MCMI
__Other __Other
__Other __Other
Time Requested for Total Testing Authorization:
Administration Time: _________Hours
Scoring Time: _________Hours
Write Up Time: _________Hours
Psychologist’s Signature, Title, License # Date
Where to send form:
For Medi-Cal and Group Home Consumers, fax completed form to Central Access Team at (951) 358-5352 or mail
to MHP: CAT PO Box 7549, Riverside, CA 92513
For DPSS consumers of ACT, fax completed form to (951) 687-5819 or mail to MHP: ACT, PO Box 7549, Riverside,
CA 92513