Assessment Intake Form

Please complete this form before attending your intake/initial meeting with the assessment psychologist.

Name of person completing the form

First NameLast Name

Email

example@example.com

Phone number

Address of Participant

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address of second parent/carer/guardian - if applicable

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

For children under 16, are both parents aware of the referral?

Who is this assessment for?

First NameLast Name

Date of Birth

Date

Gender

Preferred Pronouns

School Level (If applicable)

School (If applicable)

Name and role of key contact at school (ex.Lisa Sample, Learning diversity leader)

Contact details of key contact at school

REFERRAL DETAILS - Please outline your concerns or reasons for wanting an assessment at this time: Example. Learning; behaviour; social; communication details

What has been tried: (e.g., extra tuition? ExtraHomework? any help from school or school systems such as RTLB?; home support;etc. – and what worked.)

Vision and Hearing - Date of last assessment/s? Results/any concerns?

Significant family history:

School history/attendance:

Parent/carer/guardian intake sessionscan occur in-person or virtually, using the Zoom or Teams platform.Instructions will be provided. Scheduling for these sessions can be flexible.Do you have any time preferences or limitations?Ex. In-person, Thursday afternoons

Please indicate your day and timepreferences for your/your child's testing sessions.While we cannot guarantee availability, we will try our best to meet them.PLEASE NOTE: We have very limited availability for Saturday appointments.Please indicate alternative days that would work for your schedule. Unfortunately,at this time, we cannot offer times outside of those listed.

Do you have any questions or comments, or is there any other information we should know at this stage?

Date completed

Date

Psychology Assessment - Intake Form