Assessment Intake Form

Assessment Intake Form

Estimated time 5-10min, includes required fields*
Date*

DayMonthYear
Date
Participant Name*

First NameLast Name
Participant's Address

Street Address

Street Address Line 2

CityState

Post Code
Participant E-mail Address (if applicable)
example@example.com
Years of Education
Grade
Participant's Birth Date

DayMonthYear
Age
COVID-19 Vaccination Status: *
AboriginalTorres Strait IslanderNot ApplicableOther
Contact Details
Primary Contact*
Please select one
School Contact/Coordinator

First NameLast Name
School Contact/Coordinator Phone
School Contact/Coordinator E-mail
example@example.com
School Name
Name of referring school
Parent/Guardian*

First NameLast Name
Parent/Guardian Phone Number*
Mobile or landline
Parent/Guardian E-mail
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Previous Assessments?
e.g., cognitive, educational. If so, please provide details/dates here.
Supporting documents

Browse Files
Plans, previous reports, etc. Cancelof
Diagnosis/Disability
(If required.)
Assessment

Please choose from the following options.
Educational AssessmentCognitive AssessmentDevelopmental AssessmentScreening e.g., Autism, ADHDNeurological Assessment
Notes
Further information relevant to referral
Participant funding: *
Note: We require payment on the day of your consultation. The cost of the assessment is agreed upon at the time of booking.
YesNo
Health Cover Provider (if applicable)
Note: Parents are requested to (where possible) use private cover to reduce the cost and invoice the School/Tasmanian Catholic Education Office the remaining balance.
Consent Form

*Please note: signed consent is required prior to service.
PsychiatristGPTreating ReferrerSchoolOther
YesNo
Psychological Service

As part of providing a psychological assessment to you, your child(ren) or family members, Healthstyles will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the psychological assessment that is conducted. The assessment will be used for educational planning purposes.

Access to Client Information

At any stage you as a client are entitled to access to the information about you kept on file, unless the relevant legislation provides otherwise. The psychologist may discuss with you appropriate forms of access.

Confidentiality

All personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure except where:

It is subpoenaed by a court, or
Failure to disclose the information would place you or another person at serious and imminent risk; or
Your prior approval has been obtained to

a) Provide a written report to another professional or agency, e.g. a GP or lawyer; or

b) Discuss the material with another person, e.g. a parent or employer; or if disclosure is otherwise required or authorised by law.
I have read and understand the above consent form. I agree to these conditions for the psychology service provided.
Should be Empty:

Assessment Intake Form

Contact Details

Assessment

Consent Form

Psychological Service

Access to Client Information

Confidentiality