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    Referral Letter

    Uploaded by

    Ma. Thea Diane Billones
    The document contains client information for a patient including their name, date of birth, practitioner details, diagnosis, treatment dates, medication history, and notes on suicidal ideation, harm to others, hospitalizations, and intelligence testing results. Specifically, the client has been on Tegretol 200mg for epilepsy since age 13 and experiences seizures and dissociation after episodes. An intelligence test yielded a score corresponding to an IQ of 73 or below.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Referral Letter

    Uploaded by

    Ma. Thea Diane Billones
    57 views3 pages
    The document contains client information for a patient including their name, date of birth, practitioner details, diagnosis, treatment dates, medication history, and notes on suicidal ideation, harm to others, hospitalizations, and intelligence testing results. Specifically, the client has been on Tegretol 200mg for epilepsy since age 13 and experiences seizures and dissociation after episodes. An intelligence test yielded a score corresponding to an IQ of 73 or below.

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    The document contains client information for a patient including their name, date of birth, practitioner details, diagnosis, treatment dates, medication history, and notes on suicidal ideation, harm to others, hospitalizations, and intelligence testing results. Specifically, the client has been on Tegretol 200mg for epilepsy since age 13 and experiences seizures and dissociation after episodes. An intelligence test yielded a score corresponding to an IQ of 73 or below.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    57 views3 pages

    Referral Letter

    Uploaded by

    Ma. Thea Diane Billones
    The document contains client information for a patient including their name, date of birth, practitioner details, diagnosis, treatment dates, medication history, and notes on suicidal ideation, harm to others, hospitalizations, and intelligence testing results. Specifically, the client has been on Tegretol 200mg for epilepsy since age 13 and experiences seizures and dissociation after episodes. An intelligence test yielded a score corresponding to an IQ of 73 or below.

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    © All Rights Reserved
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    Client Information

    Name:________________________________________________________________________
    Last First Middle

    Date of Birth
    _______________________________________________________________________

    Practitioner Name and


    Credentials:___________________________________________________________________

    Practitioner Type: Psychiatrist Psychologist Social Worker Mental Health


    Counselor

    Other (Please specify)


    ______________________________________________________________________________

    Patient Diagnosis (DSM Code and Name, with Specifiers)


    ______________________________________________________________________________
    ______________________________________________________________________________
    ___________________

    First Date Seen: _________________________Last Date Seen:_________________________

    Do you plan on continuing treatment with this patient? Yes No

    Does the patient have a history of suicidal or other self-harming behavior or ideation?
    Yes No

    If yes, please give details regarding number, dates, and types of incidents, their duration
    and resolution:
    ______________________________________________________________________________
    ______________________________________________________________________________
    __________________________________________________________________________

    Does the patient have a history of ideation or behavior involving harm to others?
    Yes No

    If yes, please give details regarding number, dates, and types of incidents, their duration
    and resolution:
    ______________________________________________________________________________
    ______________________________________________________________________________
    __________________________________________________________________________
    Has the patient been hospitalized for psychiatric reasons? Yes No
    If yes, please give details regarding number, dates, and types of incidents, their duration
    and resolution:
    ______________________________________________________________________________
    ______________________________________________________________________________
    __________________________________________________________________________

    Has the patient been prescribed medication by you or any other practitioner? Yes No
    If yes: Medication Dose

    The client has a maintenance of Tegretol 200mg for Epilepsy. The client started her
    medication maintenance since she was 13 years old. The client was reported to experience
    seizure and a moment of dissociation after an epileptic episode.

    Additional Note:
    The client had taken an intelligence test that was loosely modeled after Raven's

    Progressive Matrices. The test contains images that take the form of a 3x3 matrix from which

    one tile is missing. For each question there are eight possible answers A-H. The client will

    choose one answer among the choices. The final score of the client was computed and was

    interpreted for a corresponding IQ score. The client obtained an IQ score of <= 73.
    Practitioner Signature ______________________________________

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