Neuropsychological assessment request

This form is for healthcare professionals referring a patient to Centre Ados Riviera. All information submitted is encrypted and handled confidentially.

Information submitted through this form is encrypted before storage and can only be read by authorised staff at the Centre. Find out more.

Referring professional

The person referring the patient to the Centre.

Surname

First name

Role

Organisation

Telephone

We confirm receipt of the referral to this address.

Patient

Surname

First name

Date of birth

Preferred first name

Complete this if the patient prefers to be called by another name.

Patient’s telephone

Legal guardian’s telephone

Full postal address

Email address

Parental responsibility

Who holds parental responsibility?

Insurance (LAMal, AI, LAA)

Supplementary insurance

If the patient is a minor: are the parents aware of this referral?

YesNoThe patient is an adult

If not, why?

Primary care physician

The primary care physician must be aware of and approve the referral to Centre Ados Riviera.

The patient has no primary care physician

Surname

First name

Telephone

Other professionals involved

Psychologist, social worker, youth worker, special needs teacher…

No other professionals involved

Professionals involved

Name, role and contact details for each professional.

Reason for referral

Reason for the assessment request

Describe the situation, how it has developed and what you expect from the Centre.

Documents

Main document

PDF, image or Word document · 8 MB maximum

The prescription is mandatory and must be attached to the request.

Additional document

PDF, image or Word document · 8 MB maximum

Fields marked with an asterisk are required. For an urgent situation, please call 021 566 17 70.