Clinical Evaluation Referral | Lizotte Clinical, LLC

Evaluation Referral Note: Please include any court date or report deadline so the evaluation can be scheduled to meet it. I will contact the referring party within one business day to confirm scope and schedule the clinical interview.

1Evaluation Type

What type of evaluation is needed? *

Court-ordered / probationJuvenile Court & DiversionDisciplinary / expulsion reviewSchool Re-entry & TruancySUD screening & risk levelSubstance Use EvaluationDiagnostic & behavioralMental Health Evaluation

Court Date / Report Deadline

Report To Be Sent To

2Referral Source

Who is completing this form? *

Your Full Name *

Organization / Office

Email Address *

Phone Number *

3Youth Information

Youth Full Name *

Date of Birth *

Parent / Guardian Name *

Parent / Guardian Phone *

Town / City *

School & Grade

4Legal & School Context

Docket / Case Number

Assigned JCCO (if any)

Reason for referral *

Records available for review

5Acknowledgment & Consent

I confirm the youth's parent or legal guardian is aware of this referral, or I am the parent / legal guardian.I understand signed releases (ROIs) will be required before records are exchanged or a report is shared with any court, school, or agency.I understand the 7 business day report window begins once the clinical interview is completed and all requested records are received.I acknowledge that evaluation fees are listed on the rates page and payment responsibility will be confirmed before scheduling.

Signature (Type Full Name) *

Date *

Professional Evaluation Referral Form

1Evaluation Type

2Referral Source

3Youth Information

4Legal & School Context

5Acknowledgment & Consent