FORMS FOR CLIENTS
The forms below can be downloaded and printed.
If you have any questions when completing a form, feel free to contact Dr. Frerichs. Leave blank any portions in the referral or background history form that you cannot answer (missing information can be clarified later or discussed during the interview).
A fact sheet specifically about neuropsychological assessments for North of 50 Neuropsychology clients.
A referral form to be used if you would like to request services for yourself, or if you intend to refer someone else for services. The form, once completed, can be submitted online or emailed to Dr. Frerichs.
Clients seeking an evaluation for themselves may use this form to provide pertinent information about their concerns and relevant history. Normally completed after
an initial meeting with Dr. Frerichs. It can be downloaded, printed, filled out, and given to Dr. Frerichs at the time of the assessment, or faxed or mailed to him before the scheduled assessment. The information is valuable and can help reduce time spent in interview.
Similar to the client history form but intended for a substitute decision-maker (e.g., legal guardian), close family member, or other third-party to provide pertinent information about the adult who is to be assessed. Normally completed after
an initial meeting with Dr. Frerichs once consent has been obtained from the examinee or the examinee's legal guardian.