CReATE Adult Professional Referral Form

Please complete the following information so that we can better determine the type of evaluation needed. The information submitted in this form is guaranteed to be kept confidential and secure.
 

Professional Information

Your Name: *
Specialty or License Type: *
Practice or Program:
Would you like to speak with us?
If yes, Phone Number:
If yes, Email:  
Preferred Method of Contact:

Client/Patient Information

Client Name: *
Biological Sex/Gender: *(please specify if different)
Birth Date/Age mm/dd/yyyy*
Phone Number:
Email:  

If we need to contact someone else on behalf of the client (e.g. spouse, parent, or caregiver),
please list the contact information for that individual below:
First and Last Name:
Relationship to client (e.g. parent/spouse):
Phone Number (if different):
Email Address (if applicable):

Reason for Referral:

Briefly describe the reason for referral, concerns, or a little about the patient or client’s current difficulties:

What would you (or the client) like to learn from this evaluation?

How long have these concerns/difficulties been present (months, years, or age at which concerns/ difficulties began):

Were these concerns/difficulties the result of a known event/injury (e.g., brain injury, stroke, illness etc.)?
If Known Event, please check all that apply:
Please describe the event(s) including dates, if possible:


Do you have concerns regarding recent heavy substance use (alcohol or other substances)?
Is the client/patient in school or planning to return to school?
Are you aware of any legal action currently underway or pending?
If yes, please describe:

Have you discussed your reasons for referral with the client/patient?
Are you referring to a specific psychologist? Name:
Please let us know if there is anything else we should know or be aware of in working with this client/patient and/or their family?

Area of concern:























Type of Evaluation (check all that apply):

Other - Description:

Medical Records:

Which of the following scans/tests have previously been performed (please check all that apply):
 
Do you have records to send us? (This may include a copy of your assessment, medical records, school records, mental health records, application for the client/patient to attend your program, prior testing, etc.) We can accept records by fax (888-224-5899) or create a file for you to upload records on to our secure EMR site. If you would like us to create a file and send you the link, let us know. This file can then be used to upload future referral records as well