Assessment Referral Form
Please fill in the patient/child's details below
Title
*
Master
Miss
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please fill in the parent/legal guardian's details below (1)
You will be the main point of contact and Medicare claims will be sent under your name on behalf of your child
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Phone Number
*
E-mail
*
example@example.com
Relationship to Patient
*
Occupation
Referring Doctor
GP Doctor (if different from above)
Medication List inc. strength, no. of tablets and times taken
Assessment Information
Assessment you are looking at getting your child assessed for
*
Learning Problems
ADHD
Autism
Combined
If you have a preferred type of psychologist to conduct the assessment
*
Registered Psychologist
Clinical Psychologist
Happy to be booked with any Psychologist
How soon are you looking for an assessment
*
As soon as possible
Within 2 - 3 months
Within next 6 months
Do you currently have a Paediatrician or Psychiatrist looking after ongoing care for your child
*
Yes
No
Is there a court order or split custody arrangement is in place for this child
*
Yes
No
If YES, I understand the court order documents must be supplied and both parents must consent for this assessment to go ahead
*
Yes
No
Any other information you would like us to know about your child and possible assessments
Terms and Conditions of Ongoing Care and Treatment
I understand that the medical information collected at the practice will be used to provide clinical care, administrative purposes, to record your health information, billing purposes, including compliance with Medicare and insurance requirements. It may be necessary to disclose this information to fulfil medical insurance obligations.
*
Yes
I consent to be contacted about my child's assessment with the information I have provided
*
Yes
Parent's Name
*
First Name
Last Name
Signature
*
Date
-
Day
-
Month
Year
Date
Submit
Should be Empty: