Adult Psychology Preassessment Questionnaire

Adult Psychology Pre-Assessment Questionnaire
The information you provide in this questionnaire will be used to assess whether SPELD SA can provide the type of assessment you need. It will not be shared or used for any other reason. Once you have submitted this questionnaire, someone from the SPELD SA Psychology team will contact you by phone to discuss the process in more detail and to answer any questions you have.
Name*

First NameLast Name
Contact Phone Number *

Area code Phone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

SuburbState

Post CodeCountry
Date of Birth*

DayMonthYear
Date
Are you currently enrolled in study? If so, what course and level are you studying?
eg; High school year 11, First year Bachelor degree etc
Do you identify as Aboriginal or Torres Straight Islander?*

YesNo
Have you previously participated in assessment or therapy with any of the following?

PsychologistSpeech TherapistOccupational TherapistOther
Please provide brief details of any reports, diagnosed conditions, or ongoing therapy.
Do you have a vision or hearing impairment?*

YesNo
Date of last hearing assessment

DayMonthYear
Date
Date of last vision assessment

DayMonthYear
Date
Why are you seeking a SPELD SA assessment?*
Areas of Difficulty

Please provide a brief description of difficulties experienced in any of the following areas:
Reading
Spelling
Written Expression
Maths
Attention or concentration
Organisational Skills
What types of help have you had for these difficulties, including when you were a child? (Tutoring, Intervention Program, Literacy Course etc)
Please note that a Specific Learning Disorder diagnosis cannot usually be given without evidence of at least six months of targeted intervention to correct learning problems.
Are there any other details that might be relevant?
Preferred location for assessment*

Frewville (259 Glen Osmond Road)Online
How did you learn about SPELD SA?

SPELD SA websiteReferred by my UniversitySocial MediaGoogle / Internet searchFriend / FamilyOther
Submit Form

To submit the form online, you will need to enter the Captcha word below and then click the SUBMIT button. You will receive an email copy of the information you have provided for your records. Someone from the SPELD SA Psychology team will contact you in the following week to discuss the next steps.
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Adult Psychology Pre-Assessment Questionnaire