4th Floor Sherbrooke Centre
New Westminster, BC
V3L 3M2 Canada
Tel (604) 520-4662
Fax (604) 520-4871
www.fraserhealth.ca
REFERRAL FORM – NEUROPSYCHOLOGICAL ASSESSMENT SERVICES
Date of Referral (dd/mm/yr):
PHN:
Last Name:
First Name:
DOB (dd/mm/yr):
Address:
City:
Home Phone:
Occupation Status:
Please circle:
Inpatient
Outpatient
Floor _____
First Language:
Interpreter Needed:
Y
N
If they cannot be seen as an inpatient, do you want them seen as an outpatient?
Y
N
PLEASE PRINT LEGIBLY
Referral Source (Name of Person and Site):
Phone:
Address:
Fax
CURRENT 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 Report
DATE 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 Fraser
Health 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 need
intelligence testing done.