Testing | Psychology Institute of Las Vegas

Testing Patient Request

Psychological and Neuropsychological Testing is a specialized service that PILV provides. Please provide us with as much information as possible so that we can best assist with your request.

Patient First Name

Patient Last Name

Parent or Guardian (If Patient is unde 18)

Age

Patient Date of Birth

Phone

Best time to be reached

Why is testing being requested? What difficulties is the patient experiencing?

Has the patient ever been tested in the past?

Yes

If yes, when?

If yes, for what reason?

Is the patient's first language English?

Yes

Are there any difficulties with hearing, vision, or mobility?

Has a medical provider referred the patient for testing?

Yes

If yes, who is the referring provider?

Other Insurance Type (If necessary)

Insurance Member ID

What is the name of the primary person on the insurance policy?

Thanks for submitting!

Testing Patient Request

Accepted Insurance (Please contact us for our out-of-pocket rates)

Accepted Insurance
(Please contact us for our out-of-pocket rates)