Assessment Enquiry Form

Assessment Enquiry Form

Please complete this form (takes approx. 5 mins) to help us consider the next steps in your assessment process. If you would prefer to provide this information verbally, please let us know you would like a phone call instead.
Current availability

Are you seeking an in-person or Telehealth assessment?
In-person Toowoomba: next available September 2026Telehealth: next available May 2026
Contact details
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Gender
Other details
Pronouns

she/herhe/himthey/themother
Other
Preferred contact method*

EmailPhone callSMS
Phone number*
Please enter a valid phone number.Format: (0400000000).
Email*
example@example.com
Address*

Street Address

Street Address Line 2

SuburbState

Post code
*

I would like to book a 1 hour session to explore possible assessment before booking a full assessment.I would like to go ahead and book my assessment.
Assessment options

NeuroAffirm only offers assessment/diagnosis of Autism & ADHD for adults 18 years + and does not assess/diagnose other presentations eg learning disability, dyslexia, Intellectual Disability/cognitive functioning, personality disorders etc.
What assessment are you seeking?*

Autism + ADHD (adult)Autism only (adult)ADHD only (adult)Other
Details if 'other'
Why are you seeking assessment at this time?
For example, to learn more about myself, to receive recommendations for support, to take to a psychiatrist, to use as evidence for required accommodations in the workplace/study place.
ADHD & Medication

A psychologist can provide an ADHD diagnosis but is not able to prescribe medication. In Australia, only psychiatrists and GPs can prescribe ADHD medication. If you are considering medication, it may be more cost-effective to see a psychiatrist or GP directly. You do not need to see a psychologist beforehand.
Only complete if you are enquiring about ADHD assessment.

I understand that a psychiatrist or GP consultation is required for ADHD medication to be considered and prescribed. I still want to enquire about ADHD assessment with Blanche.
NDIS Considerations

Assessments provide a diagnosis and level of support required for autism. The report on its own may not provide sufficient evidence for NDIS purposes.
Please indicate your understanding below:*

I understand that I am responsible for determining if the assessment is right for my needs, including any NDIS-related considerations.
Please select the option that applies to your circumstances:*

I am not eligible / do not intend to use a Medicare rebate and will be paying for the assessment privately.I am aged under 25 years and intend to use the Medicare rebate.
Please indicate your understanding below:*

I understand that the listed prices are for standard assessments and if more time is needed to explore complexities, I will be charged at the usual hourly rate.
Mental health history
Please indicate any mental health diagnoses you have received:

Anxiety (ie worry, panic, social, phobia)DepressionTraumaSubstance dependencePersonality disorder (please provide details below)BipolarEating disorderSchizophreniaPsychosisOCDOther - please list below
Other mental health concerns or details.
Neurodevelopmental differences or brain injury
Please indicate any of the following diagnoses you have received:

AutismADHDIntellectual DisabilityLearning Disability ie dyslexia, dysgraphia, dyspraxia, dyscalculiaAcquired Brain Injury / Traumatic Brain Injury
Details
Medical conditions or illness
Please list any medical conditions or illness.
Legal matters
Do you have any current legal matters in court? For example family law court, criminal matters.*

NoYes
If yes, please provide details:
Further information and questions
Is there any further information you would like to provide? Do you have any questions?
Existing reports or documents
Do you have any existing reports or documents relevant to the assessment you are seeking? For example, psychiatrist, psychologist, OT, speech and language therapy reports. Please upload any documents below as these will need to be considered before starting an assessment.

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How did you hear about NeuroAffirm Psychology?

Google searchSocial MediaGPHealth professionalFriendExisting clientOther
Newsletter option: would you like to be added to NeuroAffirm's mailing list to receive occassional newsletters, resources, and updates?

Yes - I consent to being added to the NeuroAffirm Psychology mailing list.
Privacy Collection Statement

NeuroAffirm Psychology values your privacy and complies with the Australian Privacy Act 1988 (Cth). We collect personal information, such as your name, email, and message, when you submit our contact form. This information is used to respond to enquiries and provide support. By submitting the form, you agree to this collection statement.
Please indicate your consent below:*

I agree to the collection and use of my personal information in accordance with the Australian Privacy Act 1998 (Cth).
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Assessment Enquiry Form

Current availability

Contact details

Assessment options

NDIS Considerations

Mental health history

Neurodevelopmental differences or brain injury

Medical conditions or illness

Legal matters

Further information and questions

Existing reports or documents

Privacy Collection Statement