All Counties - Community Care Behavioral Health

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What information is testing expected to
provide that cannot be determined by a
diagnostic interview, review of
psychological/psychiatric records, or a
second opinion?
How would results of testing affect the
treatment plan?
What are the current symptoms related
to the referral question?
What is the referral question to be
answered by testing?
Medical/Psychological Evaluation:
Has client had a diagnostic interview?
No
Yes
Date of interview:
Previous Psych Testing? No Yes When, Basic Focus,
and Results:
Medications Prescribed?
Anti-anxiety Agents
Anti-Parkinsonian
Anti-convulsants
Anti-psychotic
Agents
Anti-depressants
Sedatives/
Hypnotics
Anti-manic
Agents
NONE
Other:
Is member currently attending school? No Yes If Yes, where?
Is member currently abusing any substance? No Yes If Yes, Elaborate:
Requested Testing:
Psychological Testing
(Children/Adolescents) 5 Hours
Psychological Testing
Neuropsychological Testing
(Children/Adolescents) 7 Hours
Neuropsychological Testing
Date to be Administered:
Number of Hours Requested:
Names and Types of Tests: