Assessment Referral Form
Please fill in the patient/child's details below
Name
*
Mr
Mrs
Miss
Ms
Dr
Mx
Title
First Name
Last Name
Preferred name (if different from legal name above)
Preferred pronouns
*
Please Select
She/Her
He/Him
They/Them
Prefer not to say
Another combination
Please specify:
*
Date of birth
*
-
Day
-
Month
Year
Date Picker Icon
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Title
*
Master
Miss
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Please fill in the parent/legal guardian's details below
You will be the main point of contact for discussing and booking in assessments
Name
*
Mr
Mrs
Miss
Ms
Dr
Mx
Title
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date Picker Icon
Phone number
*
Format: 0000 000 000.
E-mail
*
example@example.com
Relationship to patient
*
Occupation
Referring Doctor
Usual GP (if different from above)
Medication List inc. strength, no. of tablets and times taken
Assessment Information
Which assessment would you like to book in for?
*
Learning Problems
ADHD
Autism
Other
Do you have a preferred type of psychologist to conduct the assessment?
*
Registered Psychologist
Clinical Psychologist
Happy to be booked with any Psychologist
How soon would you like to book in this 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 in place for this child?
*
Yes
No
I understand the court order documents must be supplied and consent must be obtained as per the orders for this assessment to go ahead. In cases of split custody where there are no court orders in place, the consent of both parents is required for the 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: