Appointment Request or Enquiry Form

1
Full Name of child* This field is required.
First Name
Last Name
2
Child's date of birth
3
School Year Level* This field is required.
Preschool
Kindergarten
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
University
Not at school
4
School Name
5
Parent / Carer Name* This field is required.
Prefix
First Name
Last Name
6
Parent / Carer Name 2
Prefix
First Name
Last Name
7
Parent / carer E-mail* This field is required.
8
Parent / Carer Phone Number* This field is required.
9
Please select the item below that describes the legal parental and decision making responsibility for your child:
Married with shared parental responsibility
Separated or divorced with shared parental responsibility
Single parent family with sole custody and parental responsibility (court orders to be provided)
Separated or divorced and no court orders are in place
Other / Please call me to discuss
10
What is your child's suburb?
11
What is your child's postcode?
12
How did you hear about PosAbility Australia?
Website
Word of mouth
Teacher or school
Facebook
Online search
Referral from medical professional
Other
13
Please identify any concerns you have regarding your child (tick all that apply)* This field is required.
Handwriting and/or fine motor skills
Reading
Spelling
Writing
Mathematics
Comprehension (oral and/or reading comprehension skills)
Speech or expressive language skills
Attention or Concentration
Behaviour
Motor Coordination (e.g. throwing, kicking, balancing)
Social Skills
Emotional well-being (e.g. anxiety or depression)
Sensory processing
General developmental delay
14
Which service/s are you enquiring about? (Tick all that apply)* This field is required.
Cognitive assessment (IQ and/or adaptive functioning assessment)
Literacy assessment (reading, spelling and/or writing)
Numeracy or Mathematics assessment
Speech and Language assessment
Diagnosis of learning difficulty (Dyslexia, Dyscalculia, Dysgraphia)
Assessment for ADHD or Behaviour
Assessment for Autism Spectrum Disorder
Educational Intervention / tutoring for Reading, Spelling and/or writing
Educational Intervention / tutoring for Numeracy and Mathematics
Intensive educational or multidisciplinary intervention
Occupational therapy intervention or assessment
Counselling (including management of anxiety, support for emotional regulation or social skills development)
Speech Pathology for language or literacy
Assistance with my child's behaviour
Study Skills training
Consultation with a Director to develop a case management plan
Holiday group program
I am not sure what services I need
Other
15
Please provide further detail regarding the concerns above or reason for referral* This field is required.
16
Has your child had any previous assessments? (please tick all that apply)
IQ / Cognitive Test (e.g. WISC or Stanford Binet)
Standardised reading, spelling or writing assessment
Standardised numeracy assessment
Neuropsychological assessment
Occupational therapy assessment (e.g. handwriting, motor skills)
Speech and Language assessment (e.g. CELF)
We have not previously had any formal assessments
Other
17
What days are you available? (tick all that apply)* This field is required.Please note that not all days / times may be available and you will be offered the next available appointment based on your child's needs.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
18
I would like to be added to the PosAbility Australia's mailing list to be notified about PosAbility news and services such as holiday programs. Please note that we do not rent or sell your information to any third parties!* This field is required.
Yes
No
19
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