CReATE Professional Referral Form (Children/Adolescents)

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: *
Position or Specialty: *
Practice, Program or School:
Would you like to speak with us?
If yes, Phone Number:
If Yes, Email:  
Preferred Method of Contact:

Child/Adolescent Information:

Child or Adolescent Name *
Biological Sex/Gender: *(please specify if different)
Birth Date/Age mm/dd/yyyy*
Grade:
School:

Parent/Caregiver Information:

First and Last Name:
Relationship to client:
Phone Number:
Email Address:

Reason for Referral:

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

What would you (and/or the parents) like to learn from this evaluation?

Are you aware of any legal action currently underway or pending?
If yes, please describe:

Have you discussed your reasons for referral with the parents/guardian?
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 child/adolescent and/or their family?

Type of Evaluation:

What type of evaluation are you recommending?

Other - Description: (Optional)

Area of concern, Check all that apply:


























Medical Records:

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