Get Parent Referral Form (pdf) - Massgeneral

Filling out the Parent Referral Form for neuropsychological evaluation is an important step in seeking the appropriate support for your child. This guide provides clear, step-by-step instructions to help you complete the form accurately and effectively.

Follow the steps to complete the Parent Referral Form with ease.

1. Click the ‘Get Form’ button to access the Parent Referral Form and open it in your preferred editor.
2. In the first section, enter the patient's name and Medical Record Number (MRN). Ensure the patient is registered at Mass General Hospital by calling the Registration Center at 866-211-6588.
3. Fill in the patient's date of birth and insurance information. Note that Mass General is not contracted with CIGNA, Fallon, or Network Health.
4. If the patient is a child, provide the name(s) of the parent(s) and their contact numbers, including home, work, and cell. Include an email address to confirm receipt of the referral.
5. Indicate who recommended contacting Mass General by checking all relevant options, such as 'Parent/Self,' 'Pediatrician,' 'Psychologist/Psychiatrist,' or 'Medical Doctor/Specialist'. If applicable, provide the name/institution of the recommending professional.
6. In the section asking why you are seeking an evaluation, briefly explain your concerns about your child's mental, medical health, behavioral, or academic issues.
7. Indicate whether your child has a history of conditions listed by checking all that apply, such as 'Prematurity/low birth weight' or 'Learning Disabilities.'
8. List any known diagnoses or concerns regarding conditions like Attention Deficit Hyperactivity Disorder or Autism Spectrum Disorders. Check all that are relevant.
9. If applicable, provide details about any current or past mental health providers, including their names and phone numbers, along with a brief explanation of their involvement.
10. Mention any medications your child is currently taking, including names and dosages.
11. Check any services your child is currently receiving, such as Occupational/Physical Therapy or Special Education Services.
12. If your child has undergone previous testing, indicate the type and provide dates for academic and neuropsychological testing, if applicable.
13. After completing all sections of the form, review the information for accuracy. You can then save your changes, download the form for printing, or share it as needed.

Take the next step in supporting your child by completing the Parent Referral Form online today.