Testing Referrals

At Ascend Psychological Associates, we know you work diligently to help your patients succeed in treatment. At times, psychological testing may help in that process, and we’re glad to collaborate in your patient’s care.

Please complete this form (Ascend Psychological Testing form) and email it to testing@ascendsalina.com. Or, you may complete the following form below and it will be sent to us directly.

Date of Referral *

Patient Name *

First

Last

Patient Date of Birth

Age

Is patient currently in school? *

If yes, grade level and school

Referring Party *

Current Therapist

Current Medication Provider

Patient Insurance Provider *

Is there a deadline for this report? *

If yes, when?

Testing may take multiple sessions and most reports will be completed two weeks after testing has finished.

Do you believe the individual is actively using alcohol or drugs? *

Has the patient had a previous psychological evaluation? *

If previous psychological testing has been completed, please send a copy of that evaluation, if possible.

Briefly describe what event(s) in the case or what aspects of the person’s behavior lead to a referral for an evaluation: *

What question(s) would you like to have answered by the testing? *

Please be as specific as possible. (Ex: "Are his behaviors better accounted for by bipolar disorder or a personality disorder?")

Current or Provisional Diagnosis *

Describe any relevant medical issues

Name