501 S. Rancho Drive Suite F-37 Las Vegas, NV 89106
jbaumann401@gmail.com
Login
Sign Up
Home
About Us
Services
Psychological Evaluation
Neuropsychological Evaluation
Cognitive Behavioral Therapy
Biofeedback Therapy
Pre-Surgical Evaluation
Workers Compensation Evaluation
Independent Medical Evaluations (IME)
Pre-Employment Psychological Evaluations
Forensic Psychological Evaluations & Reports
Faq's
Referral
(702) 388-9403
Contact Us
Referral Form
REQUEST FOR CLINICAL PSYCHOLOGICAL & NEUROPSYCHOLOGICAL EVALUATION AND TREATMENT SERVICES
501 S. Rancho Drive Suite F-37 Las Vegas, NV 89106
OFFICE:(702) 388-9403
Client Name:
Social Security #:
Telephone (Home):
Cell:
DOB:
Claim #:
Date of Injury:
TYPE OF EVALUATIONS:
Psychological (to establish diagnosis/treatment plan)
Presurgical (prior to any surgery)
Neuropsychological (for TBI/CVA’s/etc.)
WORKERS' COMP REFERRAL:
Yes
No
Adjuster’s Name:
Telephone #:
Fax #:
PERSONAL INJURY ATTORNEY LIEN:
Yes
No
Attorney’s Name:
Telephone #:
Fax #:
EVALUATE AND TREAT THE FOLLOWING CONDITIONS:
Psychological contraindications to a successful recovery from surgery
Psychological factors delaying recovery from an injury/surgery/other medical conditions
Neuropsychological deficits posts TBI/CVA
Post-traumatic Stress
Travel Anxiety/Travel Reluctance
Insomnia Disorder/Sleep Deficits
Depression/Bipolar Disorder
Anxiety/Panic Disorder
Other:
Physician’s Name:
Phone:
Fax:
Diagnosis:
Type of Injury:
Workers’ Comp
Motor Vehicle Accident
Slip & Fall
Other:
Physician’s Signature:
Date:
Submit
PLEASE SEND THE FOLLOWING:
History & Physical Evaluation
Clinical Treatment Notes
Prior authorization approval code (as applicable)
Attorney information when applicable
FAX: (702)-388-9643 | EMAIL:
jbaumann401@gmail.com