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Psychological Assessment
Medigold Management Referral Form
A Psychological Assessment is a powerful resource to help employers reach a resolution in complex and serious
situations that have become 'stuck'. The intervention is most commonly used for addressing cases of long-term
sickness absence and also to measure and assess risk, either to the employee themselves, your organisation, or to
others working with them. The intervention can particularly help to support employees with a history of longterm stress related absence or complex psychological conditions that have a significant impact on their workplace
functionality. The accompanying Psychological Assessment Report is a detailed and professional analysis of the
employee’s psychological condition and risk profile. It provides an authoritative and independent assessment of
an employee’s ability to carry out their workplace responsibilities and/or to return to work if they are absent.
Employer:
Employee’s Name:
Date of Referral:
The Psychological Assessment Interview & Report Process
1.
The entire psychological assessment and report writing process normally takes between 4 – 6 hours, but
this can vary considerably. We will advise you on the estimated duration of each specific assessment.
2.
The assessment interview will normally take place at our Psychologist’s office and will last approximately
two hours. We have a UK-wide network of over 1,200 qualified psychologists.
3.
The assessment interview is a structured session during which the employee may be asked to complete a
number of psychological tests (psychometrics) and participate in a structured interview with the
Psychologist. The employee may be asked a range of questions relating to the current issues and
treatment, as well as relevant personal, family and employment history. The focus of the interview will be
to assess the implications of all the above for the employee’s ability to function at work or return to work.
4.
Our psychologist will complete a detailed report providing a professional opinion and recommendations
with regard to the employees work situation. Advice may be given on future treatment.
5.
The report will be sent to the referrer and the employee can receive a copy if requested.
6.
Treatment recommendations may be highlighted in the report. Treatment options may include face to face
counselling, Cognitive Behavioural Therapy or focussed return-to-work support. These can be organised
and managed by Medigold. We can advise you on implementing any recommendations in the final report.
Fees for Psychological Assessments:
Fees
Hourly Rates:
A Psychological Assessment is charged on an hourly basis. A typical intervention,
including a detailed written report, takes between 4 – 6 hours. Our Psychology
Consultant will advise on how long your particular case will take, as cases can vary
considerably.
£145.00
per hour
Travel Costs:
We have a UK-wide network and aim to select a psychologist who is close to the patient.
Travel costs are kept to a minim and are charged at these rates:
Travelling Time Fees
Mileage Fees
£50.00 per hour
£0.50 per mile
Psychological Assessment Medigold Management Referral Form Page 2 of 4
Name of Medigold Case Manager:
Employer: (Medigold’s OH Customer)
Purchase Order No. (if required)
Consent form status?
Completed & attached – OR – Still to come
Date of Referral:
Appointment Interview - Logistics:
Assessment interviews can normally be arranged between 10 and 14 days after receipt of this completed
referral form. To assist in arranging the date, time and location of the assessment interview, please provide
as much detail as you can on either your and/or your employee’s preferences. Please note that these stated
preferences serve as a guide and are subject to the availability of our psychologists.
(The final written psychological Report will be supplied between 7 - 10 days after the Assessment Interview).
Dates:
Give 2 or 3 date preferences for the Assessment Interview:
(note - between 10 and 14 days after we receive this referral)
Time:
Give a preferred time of day for the Assessment Interview:
Location:
State a preferred location for the Assessment Interview:
i.e. Work, home or at the psychologist’s clinic:
Employee’s Details:
Employee’s Name:
Employee’s Age & DOB:
Employee’s Telephone: (ideally a mobile)
Employee’s Home Address:
(including Postcode)
Employees Work Address:
(including Postcode)
Outline any language, cultural or
access requirements?
Does the employee know about this referral for a psychological assessment? (Y / N)
Has the employee received any previous psychological assessments? (Y/N )
(if yes, please provide details separately)
Employee’s Absence Data:
Is the employee absent at the time of this referral?
Total number of days of current period of absence?
Total number of days absent in the past 12 months?
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Your Objectives:
Summarise the Main Objectives of this Referral: What is your organisation hoping to achieve from this referral?
Specific Questions:
Detail any specific Questions / Issues that you want covered in the assessment and/or report?
Employee’s Job Description:
Summarise their job description and outline how their current circumstances (resulting in this referral) are
impacting on their ability to carry out their workplace duties.
General Background Circumstances:
Describe the main presenting issues and the key factors leading to this management referral. Please use as much
space as you require.
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Additional Background Information / Special Instructions:
Include any other relevant information here.
Please also send us any additional attachments such as OH reports, GP reports and absence records that you
believe may be appropriate.
Please list any additional documents you are sending here.