Psychological Assessment Request

Document Sample
Psychological Assessment Request Powered By Docstoc
					                                                                                                                       THE CITY COLLEGE
                                                                                                                                 Of
                                                                                                                   The City University of New York
                                                                                                                      The Psychological Center
                                                                                                                           (212) 650-6602


                                                                                                   Psychological Assessment Request
                                                                           Patient: ______________________________                 Date of Referral: ____________________
                                                                           Age: _________________________________                  Referring Clinician: __________________
                                                                           Phone: _______________________________                  Clinician Phone # ____________________
                                                                           Primary Language: _____________________                 Tester: ____________________________
                                                                           Other Languages Spoken: _______________                 Testing Supervisor: __________________

                                                                                                                                                              




                                                                           Has the patient had any prior psychological testing?          yes (date______)            no

                                                                           Why is the patient being referred for testing? _________________________________________________
                                                                           ______________________________________________________________________________________
                                                                           ______________________________________________________________________________________
                                                                           ______________________________________________________________________________________
                                                                           ______________________________________________________________________________________


                                                                           What diagnostic alternatives are you considering and why? ______________________________________
                                                                           ______________________________________________________________________________________
                                                                           ______________________________________________________________________________________

                                                                           RELEVANT INFORMATION (check all that apply):
                                                                           current past                                              current    past
                                                                                         suicidality/homocidality                                      assaultive behavior
                                                                               ¡         ¡                                                           ¡           ¡




                                                                                         psychotic/disorganized                                        drug/alcohol abuse
                                                                               ¡         ¡                                                           ¡           ¡




                                                                                         medication (if any, please note dosage and duration) ________________
                                                                               ¡         ¡




                                                                                         other (please explain) ________________________________________
                                                                               ¡         ¡
-- Converted from Word to PDF for free by Fast PDF -- www.fastpdf.com --




                                                                           SPECIAL REFERRAL QUESTIONS (check no more than 3):
                                                                           ¡                                   ¡                                         ¡




                                                                             intelligence                      residual ego resources        presence/severity of psychosis
                                                                           ¡                                   ¡                                         ¡




                                                                             character pathology               suicidal ideation             learning disability screening
                                                                           ¡                                   ¡                                         ¡




                                                                             neuropsych screen                 potential for violence        degree of depression/mania
                                                                           ¡




                                                                             other (please explain) ______________________________________________________

                                                                           If the patient is being considered as a candidate for psychotherapy, what information about personality
                                                                           dynamics, ego functioning, or object relations would be helpful?
                                                                           ______________________________________________________________________________________
                                                                           ______________________________________________________________________________________
                                                                           ______________________________________________________________________________________



                                                                           WORKING DIAGNOSIS:
                                                                           Axis I ____________________________                    Axis II ________________________

                                                                           OTHER COMMENTS:___________________________________________________________

				
DOCUMENT INFO