Process - Physician - Fraser Health Authority

4 th Floor Sherbrooke Centre Tel (604) 520-4662New Westminster, BC Fax (604) 520-4871V3L 3M2 Canadawww.fraserhealth.caREFERRAL FORM – NEUROPSYCHOLOGICAL ASSESSMENT SERVICESDate of Referral (dd/mm/yr):PHN:Last Name: First Name: DOB (dd/mm/yr):Address: City: Home Phone:Occupation Status: First Language: Interpreter Needed: Y NPlease circle: Inpatient OutpatientFloor _____If they cannot be seen as an inpatient, do you want them seen as an outpatient? Y NPLEASE PRINT LEGIBLYReferral Source (Name of Person and Site):Phone:Address:FaxCURRENT DIAGNOSIS: __________________________________________________________________________________________________CURRENT MEDICATIONS: _____________________________________________________________________________________________________________________________________________________________________________________________________________________REFERRAL QUESTION (Please be as specific): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PLEASE CHECK ALL APPLICABLE: Attention/Concentration Problems Memory Problems Problems with Orientation Seizures/Seizure-Like Symptoms History of Traumatic Brain Injury (TBI) Intellectual Functioning History of Loss of Consciousness (LOC) Significant Medical Problems – Specify______________________________________________________________________ Neurological Disorder – Specify ____________________________________________________________________________ Other Observed Cognitive Problems – Specify _______________________________________________________________PLEASE ATTACH COPIES OF THE FOLLOWING IF AVAILABLE: MRI, CT Scan Report EEG Report Previous Intellectual/Learning/Neuropsychological Assessment Psychiatric Consultation ReportDATE REFERRAL RECEIVED (dd/mm/yr): _______________REFERRAL NAME (PLEASE PRINT) _______________________________Criteria for patients to be seen by the Neuropsychology Service at Royal Columbian Hospital: (1) patients who live within the FraserHealth Authority catchment area; (2) patients who are 18 years and older, and; (3) patients associated with a mental health team.Exclusion criteria include: (1) patients involved in litigation; (2) patients injured at the workplace, and; (3) patients who only needintelligence testing done.