Assessment Intake Form

Assessment Intake Form

This intake form is clients who are wishing to have an assessment completed by Brain Balance Psychology. Following this process, Brain Balance will contact you to arrange an initial consultation.
Person completing this form (if different from client)

First NameLast Name
Client Full Name*

First Name/Birth NameLast Name
Preferred Name
Gender
Preferred Pronouns
Client Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Contact E-mail*
example@example.com
Contact Phone number*
Client Date of Birth*

DayMonthYear
Date
What is the main purpose for requesting a psychological assessment?*
What type of assessment you would like? (e.g. Cognitive assessment, ASD assessment or unsure of what is required)*
Do you have a preference for which psychologist you would like to see?*

Ms. Alana NorthMs. Rachael CheongWhomever has the soonest availability
What type of service method would you prefer? Please note telehealth is not suitable for all assessment types.*

Face-to-face consultations in clinicTelehealth via video consultationNo preference
Are you accessing any funding (such as NDIS) for this assessment?*

Yes - NDIS - please advise further intake will be required to collect relevant NDIS informationNo - I am full fee paying private client
Please list any medical conditions (e.g. allergies, asthmatic etc).*
Please provide information on the client's language and communication skills.*
Please detail any prior assessments completed that you think will be relevant.*
Please attach relevant assessment documents here.

Cancelof
Name of Emergency Contact/Next-of Kin*
Your Relationship to Emergency Contact/Next-of-Kin (e.g. sister/father/guardian)*
Contact Number of Emergency Contact/Next-of Kin*
How did you hear about us?*
Thank you for your submission. We endeavour to contact you within 24-48 hours.

If you wish to attach any other documents that you think would be helpful or relevant for your psychologist, please email them to admin@brainbalance.net.au with your full name as the subject title.
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