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PPCG
Perth Psychology Consulting Group
Pascalle R. Bosboom, MA (Clin Neuropsych) M.A.P.S. • Specialist Clinical Neuropsychologist (adults and older adults)
ABN 77419027411 • Rooms: 11 Rosslyn St, West Leederville WA 6007
E-mail prbosboom@gmail.com • mob 0432.585216 • fax (08) 9381 5714
Neuropsychological Assessment Referral Form
Patient demographics and contact information:
Name:
- If available -
DOB / / Age: Gender: M F
Address: INSERT PATIENT ID LABEL
Home ph: Mob ph:
Primary language spoken by patient:
Interpreter needed: yes no
NoK contact information:
Name: Relationship: Telephone:
Referral for neuropsychological assessment: 1st/Baseline 2nd/Follow-up
Presenting cognitive and/or psychological problem(s) or symptom(s) of concern:
Purpose of this assessment and specific referral question to be answered:
Issues to be addressed in the report:
Cognitive strengths and weaknesses Diagnostic clarification
Pre/post-surgical cognitive evaluation Decision Making Capacity
Verify change/decline in cognitive functioning Differential diagnosis
Strategies for management of cognitive/behavioural issues
Any other (please describe):
Are there any medico legal issues? Yes No. If yes, please describe:
Has the patient/client had any previous (neuro)psychological assessment(s)? Yes No
Date/place/contact person:
Please list any known previous investigation(s) in relation to referral question/reason:
Date: Result:
CT Brain / /
MRI Brain / /
PET Brain / /
SPECT Brain / /
EEG / /
Other / /
- Please attach any previous (neuro)psychological report(s) and/or relevant medical records -
Disclaimer: Requests for services are reviewed for necessity. Appointments are scheduled in the order that requests are received.
In order to process this referral effectively please ensure that you have fully completed and attached all relevant information as
failure to do so will slow down the referral and appointment process. Thank you for your assistance.
Please complete and email or print and fax *both pages*
Current/Provisional ICD-9 Diagnosis:
Check List of ICD-9 Disorders that may impact Cognitive Functions (not all inclusive)
Disorder/Disease ICD-9 Disorder/Disease ICD-9
Malignant Neoplasm of Brain_______ 191.__ Partial Epilepsy ___consciousness? 345.4/5
Benign Neoplasm of Brain 225.0 Epilepsy, Unspecified 345.9
Hemangioma of Brain 228.09 Cerebral Cysts 348.0
Unspecified Neoplasm of Brain 239.6 Anoxic Brain Damage 348.1
Diabetes with Neurological Symptoms 250.5 Encephalopathy, unspecified 348.30
PKU Syndrome 270.1 Cerebral Edema 348.5
Sickle Cell Disease 282.6 Unspecified Condition of Brain 348.9
Dementia __________ 290.__ Toxic Encephalopathy 349.82
Vascular Dementia 290.4 Coronary Atherosclerosis 414.0
Alcohol Induced Amnestic Disorder 291.1 Subarachnoid Hemorrhage 430
Alcohol Induced Dementia 291.2 Intracerebral Hemorrhage 431
Cognitive Disorder, NOS 294.9 Subdural Hemorrhage 432.1
Autism 299.0 Intracranial Hemorrhage, NOS 432.9
Asperger’s Disorder 299.80 Precerebral Artery Occul/Stenosis 433.__
Other Developm. Disorder ______ Cerebral Thrombosis w/Infarction 434.01
Postconcussion Syndrome 310.2 Cerebral Embolism w/Infarction 434.11
Bacterial Meningitis 320 Cerebral Artery Occlusion, NOS 434.9
Non-Bacterial Meningitis 321 Cerebral Atherosclerosis 437.0
Acute Disseminated Encephalitis 323.6 Hypertensive Encephalopathy 437.2
Intracranial Abscess 324.0 Cerebral Vascular Disease, NOS 437.9
Leukodystrophy ____________ 330.__ Cognitive Deficits due to CVD 438.00
Alzheimer’s Disease 331.0 AVM of Brain 747.81
Frontotemporal Dementia 331.1 Gestational Exposure to Toxins 760.72
Communicating Hydrocephalus 331.3 Memory Loss 780.93
Obstructive Hydrocephalus 331.4 Altered Mental Status 780.97
Mild Cognitive Impairment 331.83 Skull Fracture w/________LOC 800.__
Parkinson’s Disease 332 Concussion LOC < 1 Hour 850.10
Huntington’s Chorea 333.4 Concussion (LOC = 1 – 24 Hour) 850.20
CNS movement disorder, NOS 333.9 Concussion LOC > 24 Hours 850.30
Multiple Sclerosis 340 Cerebral Subarachnoid Hematoma 852
CNS Demyelinating Disease, NOS 341.9 Cerebral Subdural Hematoma 852.2
Epilepsy Generalized Nonconvuls. 345.0 Coronary Atherosclerosis 414.0
Generalized Convulsive Epilepsy 345.1 Closed Intracranial injury, NOS 853
Petit Mal Status Epilepsy 345.2 Open Intracranial Injury, NOS 853.1
Grand Mal Status Epilepsy 345.3 Intracranial Injury, Unspecified 854___
Does the patient have a psychiatric diagnosis (e.g. depression or anxiety)? Yes No If yes, please describe:
Is the patient currently taking medication? Yes No If yes, please list:
Is there substance use relevant to the presentation? Yes No If yes, please describe:
Does the patient have a past history of brain impairment? Yes No If yes, please describe:
Are you aware of any factors that may put neuropsychologist at risk (e.g. aggressive behaviours)? Yes No
If yes, please describe:
Other relevant information (e.g. hearing, vision, mobility, (I)ADL, medical history):
Referring clinician information: Referral date: / /
Neurologist Psychiatrist Name:
Psychologist Geriatrician
Address:
GP Other:
Ph: Fax:
Disclaimer: Requests for services are reviewed for necessity. Appointments are scheduled in the order that requests are received.
In order to process this referral effectively please ensure that you have fully completed and attached all relevant information as
failure to do so will slow down the referral and appointment process. Thank you for your assistance.
