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New client
This is specifically for individuals who are new to NDS. This form is completely confidential and the privacy of the individuals are completely secure and protected by NDS.
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* Indicates required question
Email
*
Your email
NDS client (name and surname):
Your answer
Client's cell phone number:
*
Your answer
Client email address:
Your answer
What is the client's date of birth?
MM
/
DD
/
YYYY
What age group is the client in?
*
4-5 years old
Grade R-3
Grade 4-7
Grade 8-12
University
Employed
Other:
If the individual is at school, which school are they enrolled in?
Your answer
Has the client been for an official Education Psychology assessment?
Yes
No
Clear selection
If yes, has the client been formally diagnosed? If yes, what is the diagnosis?
No
ADHD
ASD
Dyslexia
Sensor processing disorder
Anxiety disorder
OCD
Other
If "other", please stipulate:
Your answer
What is the preferred medium of appointments?
Online
In desired location (child's school)
At the practice in Stellenberg
Please provide the physical address of the preferred location: (if applicable)
Your answer
Which services would you like to solicit from NDS:
*
Neurodiversity support
ADHD skills development
Overall learning support
One-on-one homework
Group homework sessions (at practice)
Brain gym
Study skills
Tutoring
Other:
Required
If tutoring was selected, please specify the subjects to be tutored:
Your answer
How often would you like to make an appointment?
Weekly
Twice a week
Once every two weeks
I would like to be guided by the NDS therapist on my child's need
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