BRIGHAM AND
WOMEN’S HOSPITAL
HARVARD
MEDICAL SCHOOL
Center for Brain/Mind Medicine
Division of Cognitive & Behavioral Neurology; Division of Neuropsychiatry; Neuropsychology Team
221 Longwood Avenue
Boston, Massachusetts 02115
Tel: (617) 732-8060, Fax :( 617) 738-9122
Date: ____________________
Patient Name: ________________________________________________________________
BWH Number: _______________________________________________________________
Referring Provider Name: _______________________________________________________
Referring Provider Signature: ____________________________________________________
Diagnosis: ___________________________________________________________________
Chief Complaint: ______________________________________________________________
Please review the following services that our Center provides and select
the service(s) for which you are referring your patient.
The Division of Cognitive and Behavioral Neurology offers expertise in:

Behavioral Neurology – Neurologic evaluation by a behavioral neurologist.
Behavioral neurologists focus on the diagnosis and treatment of neurodegenerative diseases and neurobehavioral
syndromes that impair cognition and function (e.g. Alzheimer’s disease, Dementia, disorders of cognition,
memory, attention, language, etc.).

Neuropsychology – Cognitive testing/ assessment by a neuropsychologist.
Neuropsychologists provide a quantitative assessment of cognitive and psychological functions, and compare a
patient’s performance against age-appropriate norms. These specialists help determine a diagnosis and develop
treatment plans. Testing can take 3-5 hours.

Neuropsychiatry/ Geriatric Psychiatry – Psychiatric evaluation by a neuropsychiatrist or a geriatric
psychiatrist
Neuropsychiatrists evaluate and treat patients who have psychiatric or behavioral difficulties due to underlying
neurological conditions (e.g. Dementia, Epilepsy, head injury, Stroke, etc.).
Geriatric psychiatrists have expertise in the evaluation and treatment of psychiatric and behavioral difficulties
occurring in late life.
Please complete and fax to (617) 738-9122