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New Client Psychology Services Request Form
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* Indicates required question
Email
*
Your email
Please see our ASD Assessment process for your information
Client's first name
*
Your answer
Client's last name
*
Your answer
Client's date of birth
*
MM
/
DD
/
YYYY
Type of services required
Autism (ASD) assessment
ADHD assessment
Specific Learning Difficulties i.e. Dyslexia
Cognitive assessment (IQ)
Intellectual Disability
Counselling services (please note that my working day is Thursday from 10am to 2pm only)
Other:
Clear selection
Have you done a language assessment? (We require a language assessment BEFORE you come to us for an ASD assessment.)
Yes - please provide your language assessment report on the date of appointment
No - please contact 03 4156 8888 to schedule a language assessment
Clear selection
If other assessments or more than one assessment is required, please specify the assessments (if you know)
Your answer
Do you have a referral from a paediatrician / psychiatrist?
Yes
No. If no, you will require a referral from a paediatrician / psychiatrist to receive Medicare rebates for an ASD assessment.
Clear selection
Is the client an NDIS participant?
Yes - Please provide a copy of your plan on the day of the appointment
No
Clear selection
Funding sources
NDIS Self-Managed - Please note that NDIS funds cannot be used for an ASD diagnostic assessment.
NDIS Plan-Managed - Please note that NDIS funds cannot be used for an ASD diagnostic assessment.
Medicare - CDM plan /Mental Health Treatment Plan/ TCA plan
Medicare - Paediatrician referral - Helping children with autism plan
Private pay - Private health insurance
Private pay - out of pocket
Other:
Clear selection
Name of person completing the form
Your answer
Relationship to client
Your answer
Contact number
Your answer
Email
Your answer
Are there any court proceedings regarding the living arrangements of the client?
Yes
No
Clear selection
If yes, please provide details of the living arrangements.
Your answer
Please provide a brief summary of concerns for your child.
Your answer
Any other information?
Your answer
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