WWC Psychological Assessment Referral Form For First Responders & Military Members Confidential – For Professional Use Only SECTION A: REFERRING PARTY INFORMATIONReferring Provider / Agency Name:Professional Title / Credentials:Organization / Unit:PhoneFax:Email Date of referral: MM slash DD slash YYYY Payment Source:Pre-approvedFile number/ID:Invoice to:Assessment Fee Limits Add RemoveSECTION B: CLIENT / MEMBER INFORMATIONFull Name First Last Date of Birth:(Required) Month Day Year Sex/Gender:(Required) Male Female Other Prefer not to say Service Category:(Required) Military Veteran Police Firefighter Paramedic Other Select AllService Branch / Department:Rank / Role (if applicable):Years of Service:Is the client aware of and consenting to this referral?(Required) Yes No SECTION C: REASON FOR REFERRALPrimary Assessment Purpose: (check all that apply) Diagnostic clarification PTSD / trauma-related concerns Return to work readiness Occupational stress injury (OSI) Other (please specify): Brief Description of Presenting Concerns / ContextSECTION D: RELEVANT BACKGROUNDCurrent Diagnoses (if applicable):Known Psychiatric History: None Known Depression Anxiety PTSD Substance Use Personality Disorder Psychotic Disorders Other OtherMedical Conditions Impacting Assessment: None Known TBI Head Injury Chronic Pain Sleep Disorder Other OtherCurrent Medications:SECTION E: ASSESSMENT LOGISTICSPreferred Assessment Location: In person (if appropriate) Virtual (if appropriate) No Preference Is the client currently on medical leave or restricted duty? Yes No Unknown SECTION F: SUPPORTING DOCUMENTS☐ Consent to release information ☐ Previous psychological / psychiatric reports ☐ Incident or critical event reports ☐ Work status letters ☐ Physician referrals ☐ Insurance correspondence (Attach/submit all that are applicable) Drop files here or Select files Max. file size: 200 MB. SECTION G: REFERRAL OUTCOME REQUESTWhat type of report or feedback is being requested? Full psychological assessment report Summary letter with findings Recommendations for treatment Return-to-work recommendations Other Select AllOtherWho should receive the report/results? Referring provider only Client Employer / Agency (specify): Insurer (specify): Employer / Agency (specify):Insurer (specify):SignatureDate MM slash DD slash YYYY
