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Provider Referrals

Is the patient a minor?
Current symptoms to be evaluated:
Additional Symptoms:
Current Substance Use?
If Yes, what substances are used?
Has the patient been tested before?
Are any previous medical records available?
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Is the referral for a presurgical evaluation?
Is the patient aware that you are referring them for testing?

Thank you for referring your patient to The Psychology Institute of Las Vegas. Our Assessment Team will review your request ASAP and reach out to your patient to schedule a consultation, and/or we will contact you for further information.

Thank you for referring your patient to The Psychology Institute of Las Vegas. Understand that when patients utilize their insurance coverage for psychological and neuropsychological testing services we are required to justify services based on “medical necessity”.  When completing this form:

  1. Please indicate the need for testing services and include any clinical information to support your request, and

  2. Attach any medical records that support the patient’s current diagnosis and treatment history that is most related to the need for testing (i.e., most recent office visit notes indicating level of current impairment/concerns, radiology results, blood work, medication list, etc.)

The PILV Assessment Team will review the referral information ASAP and determine if we can meet the needs of your request. 

Thank you for allowing us to assist with your plan for patient care.

Dr. Danielle Moreggi

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