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Appointment

Today's Date:  9/23/2017  

Person completing the Clinical Referral Form


Has the client/family member been seen at UNCH Hospitals/UNC Healthcare for any reason before?

UNCH Medical Record Number:    

CLIENT/FAMILY INFORMATION:

Client/Patient Name:
 First:      Middle:     Last: 
Age:       Date of Birth: mm/dd/yyyy
Nickname:      
Gender:  
Grade in School:    
 Home Schooled:   
Name of PRIMARY CONTACT/Caregiver for Client:  
Relationship to Client
Mailing Address:  
  City    Zip Code:
Contact Information: Home ( )  -  Cell  ( )  -
  Work  ( )  -  E-mail
Name of Legal Guardian, if different from Primary Contact:   
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:)  
 REFERRING PROFESSIONAL CONTACT INFORMATION (If applicable):    
 Name:
 Discipline:  
   
Practice, Agency, or School Name:  
   
   
  Phone: ( )  -   Ext:   Fax:( )   -  

 

Will your child need any special accommodations? (For example, needs interpreter for the deaf, translator for another language, fearful of leaving parent, etc.)
What is the primary language spoken at home:

 

 1) Is the client/family member being referred by a professional for a consultation with a particular discipline or specific professional at the CIDD?
 
 

  2) Has your client/family member ever had any of the following educational assistance plans? (check all that apply)

  3) Is your client/family member involved in any of the following therapies or treatments? (Check all that apply)    




  4) Does your client/family member have a previous developmental, mental, psychiatric, or learning disability diagnosis?
Diagnosis   Approximate Date
of Diagnosis
  Professional Disciplines
Making the Diagnosis
Name of Professional
(or Agency if known)

  5) Has your client/family member ever had any cognitive (also known as Intellectual or "IQ") testing?    
   
  Type of Test
(if known)
Approximate
Date of testing
  Composite
Test Score
  School Based or
Non-School Based
Assessment

  6) Is assessment for an Autism Spectrum Disorder (Autistic Disorder; PDD NOS; Asperger's  Disorder, High Functioning Autism) an important question for you regarding your client/family member?    

  7) Are you seeking treatment for an Autism Spectrum Disorder (Autistic Disorder; PDD NOS; Asperger's  Disorder, High Functioning Autism)?    

  8) Are you seeking treatment or therapy for another developmental disability?    

  9) Are you seeking a behavior management plan?    

  10) Are you seeking medication management?    

  11) Are you seeking IQ and/or achievement testing?    

  12) Please describe your concerns regarding your client/family member in the following areas below:
  AREA OF CONCERN:   DESCRIPTION OF YOUR CONCERNS:
Behavioral and/or
Emotional Concerns:
(e.g., anger; depression; activity level)
Learning Difficulties/
Challenges;
(e.g., reading; memory; writing processing)
Speech-Language or
Communication
Concerns:
(e.g., understanding what is said; talking)
Social Development
Concerns:
(e.g., making friends
Motor/Movement
Concerns:
(e.g., walking; balance; gross & fine motor skills)
Medical Concerns:
(e.g., seizures; genetic disorders; medications)
Other/ What are the
main questions you
hope to have answered
by an evaluation or
consultation at the
CIDD?
Please Note:
At this time, our center offers clinical evaluations that target individuals whose previous assessments and/or services in their local area have not fully enhanced their learning, development, and/or treatment. If you have not pursued assessment in your local area, please be aware that the CIDD may suggest that you do so. Due to the nature of our services, we have limited appointment availability and variable waiting lists for our services. Depending upon a person’s needs, evaluation services may be provided by individual clinicians, small teams of 2 or 3 clinicians, or a full interdisciplinary team. This form will be reviewed by our clinical staff to determine the disciplines to include in the evaluation. We will contact you as soon as this form is reviewed. Thanks in advance for your patience!


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