Patient's Name:

Date of Birth:

We greatly appreciate your referral to the Drake Center Department of Medical Psychology and Neuropsychology for an evaluation. Our outpatient sevices currently include neuropsychological testing to determine the early effects of neurodegenerative disorders ("mild cognitive impairment"), dementia, and the cognitive consequences of other neurological and medical problems. We do not evaluate for the effects of psychiatric illness. To provide the best care for your patient, we ask that you provide us with the information requested below. If you have questions regarding types of testing, treatment or the information we are requesting, please contact us at 513.418.4725.

Referring Physician:

Name:

Phone:

Where should we send your final report?

Address:

City:

State:

Or if you prefer:

Fax:

For what reason are you referring this patient to us for neuropsychological evaluation?

Please supply the following:

Patient Data Sheet

Notes from the patient's most recent visit

Initial evaluation (patient's first visit with the referring physcian)

Records of any previous neuropyschological evaluations

Results of labs, CT/MRI, EEG, etc.

Most recent MMSE (mini mental-state examination) and date administered

Any other pertinent records

If you have any questions regarding the patient's appointment or non-clinical questions, please contact our Outpatient Scheduling Department at 513.418.2798.