The Carolina Institute for Developmental Disabilities at UNC
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REFERRAL INFORMATION:
Today's Date:  2/23/2018  

Is this request for services being made to address a preexisting developmental disorder (for example, intellectual disability, autism, or neurogenetic syndrome) or learning problem, or due to a concern regarding a possible developmental disorder?

Person completing the contact form


Has the patient been seen at UNCH Hospitals/UNC Healthcare previously for any reason?


Has the patient been seen at the UNC Carolina Institute for Developmental Disabilities previously?


Person Who Referred You to the CIDD?

Role of Referring Provider (if applicable):




Contact Information for Referring Provider:

PATIENT/FAMILY INFORMATION:

Client/Patient Name:
 First:      Middle:     Last: 
Nickname:      
Age:       Date of Birth: mm/dd/yyyy
Gender:


 
Current School Setting:




Grade in School:    
Name of PRIMARY CONTACT/Caregiver for Client:  
Relationship to Patient




Mailing Address:  
  City    Zip Code:
Primary Phone Number: ( )  -
 Secondary Phone Number:  ( )  -
 E-mail address:
This email belongs to:


Name of Legal Guardian, if different from Primary Contact:   

GUARANTOR INFORMATION:

Name of GUARANTOR (person responsible for payment):  
Guarantor's Date of Birth:       
Mailing Address:
 
     

PRIMARY INSURANCE PROVIDER:  
SECONDARY INSURANCE PROVIDER:
Name of PRIMARY CARE PROVIDER
(If applicable:)
 

BACKGROUND INFORMATION:

Does the patient have any previous developmental, psychiatric, or learning disability diagnoses (e.g., autism spectrum disorder, intellectual disability, generalized anxiety disorder, etc.)?


Does the patient have any previous medical diagnoses (e.g., deaf or hard of hearing, genetic diagnosis, traumatic brain injury, epilepsy, visual impairment)?


Has the patient ever had any cognitive (also known as intellectual or “IQ”) testing?


Has the patient ever had any of the following educational assistance plans? (Check all that apply)




Is the patient currently involved in any of the following therapies or treatments? (Check all that apply)








APPOINTMENT NEEDS:
Does the patient/family need any special accommodations? For example, does the patient/family need an interpreter for the deaf, interpreter for another language, or is the child fearful of leaving parent, etc.?


What is the primary language spoken at home:


 Is there a particular team or professional you are wishing to meet with at the CIDD? Please note that we may not be able to accommodate all specific requests.    


 Are you requesting a diagnostic evaluation to assess for possible autism spectrum disorder? That is, are you questioning whether the patient has autism, Asperger’s syndrome, or a pervasive developmental disorder?

Do you have concerns that the patient may have an intellectual disability/significant cognitive delays?

Are you seeking a developmental or cognitive (i.e., IQ) testing?

Are you seeking an academic/achievement evaluation? (If this is the only request, we recommend checking with your school district about a psychoeducational assessment. We currently offer self-pay options for academic evaluations since these are typically not covered by insurance.)

Are you seeking psychiatric medication management services?

Are you seeking behavior management consultation?

Are you seeking a speech-language evaluation/consultation?

Are you seeking therapy or treatment for autism spectrum disorder?Please note we offer limited therapy and group intervention services. If you are seeking ongoing speech, physical, or occupational therapies, please consult your current medical/care providers for more appropriate referrals.

Are you seeking therapy or treatment for another developmental disability? Please note we offer limited psychotherapy and group intervention services. If you are seeking ongoing speech, physical, or occupational therapies, please consult your current medical/care providers for more appropriate referrals.

CURRENT CONCERNS

Do you have concerns about behavior (e.g., aggression, self-injury, disruptive behavior, etc.)?

Do you have mood-related concerns (e.g., anxiety, depression, etc.)?

Do you have concerns about learning (e.g., significant cognitive delays, reading, writing, memory, processing speed)?

Do you have speech-language or communication concerns (e.g., understanding what is said, expressive language, conversation difficulties)?

Do you have social development concerns (e.g., making friends, relating to others, social insight, etc.)?

Do you have motor/movement concerns (e.g., walking, balance, motor skills)?

Do you have any medical concerns (e.g., seizures, genetic disorders, medication concerns, toileting difficulties, etc.)?

What are the other main questions you hope to have answered by an evaluation or consultation at the CIDD? Please note any additional information relevant to your request.

 



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