Insight Psychology, PLLC

Referring a Medical Patient

For referring physicians and staff only: To refer a patient for assessment, please download and complete the fillable form below (either the MS Word or the Adobe PDF version) and then fax it to the number above. Please indicate whether the patient will call or whether the patient has been told that the psychologist will call them. Please consider including with the referral form a summary of care and any other records that the psychologist should review.

Referral Form - Medical: MS Word

Referral Form - Medical: PDF

 

Referring a Job Candidate

For referring employers only: To refer a candidate for assessment, please download and complete the fillable form below (either the MS Word or the Adobe PDF version) and then fax it to the number above. Please indicate whether the examinee will call or whether the candidate has been told that the psychologist will call them. Please consider including with the referral form any relevant records that the psychologist should review as part of the assessment.

Referral Form - Personnel Screening: MS Word

Referral Form - Personnel Screening: PDF

Background Questionnaire: PDF

Informed Consent Form - Personnel Screening: PDF

Appointment Letter - Personnel Screening: PDF

Release of Information

To request the release of protected healthcare records from us to a third party, or to ask a third party to release protected healthcare records to us, please download, fill out, and sign the form below. Give the signed form to the person or organization you wish to release the records, and ask them to give you a copy for your records. Also use this form to authorize telephone consultations and other forms of communication between different parties.

Release Authorization Form

 

 

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