NEUROPSYCHOLOGY REFERRAL FORM
 (You may also print this page, complete and fax it to: (012) 320-0155)

Referring Doctor:
Pr Number:

Name of Patient:

Symptoms/ Diagnosis:

Current Medications:

Reason For Referral: (Please indicate with a tick)

Diagnosis/Differential Diagnosis

Norma/neurol; neurol/psychiat; differentiating between neurol conditions

Cognitive rehabilitation after neurological condition (attention, memory, speed of information processing.) Biofeedback.
Localization of brain lesion

Behaviour therapy for behavioural problems after neurological condition

Evaluation: motor, behavioural or cognitive effects of brain surgery Behaviour therapy & other psychotherapy directed at patient and family/spouse.

Evaluation: motor, behavioural or cognitive effects of medication

 Third Party Evaluations (Lawyers).
Assessment of: motor functions School-related problems
Assessment of: verbal functions Work-related problems
Assessment of: attention & concentration Problems in interpersonal relationships
Assessment of: memory    
Assessment of: abstract thinking    
Assessment of: intelligence: IQ    
Assessment of: Personality & behaviour    

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