Assessment Intake Form

Assessment Intake Form

Please complete this form 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.
Contact details

We will only contact you via your preferred method.
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.
Email*
example@example.com
Address

Street Address

Street Address Line 2

SuburbState

Post code
Assessment needs

Blanche only offers assessment/diagnosis of Autism & ADHD for adults over 18 years of age 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'
With your assessment, you can receive either a detailed report or a shorter summary letter. Which would you prefer?

ReportSummary letter
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

Only a psychiatrist can prescribe medication for ADHD in Australia. If you are wanting to trial medication for ADHD, it may be more cost effective to consult directly with a psychiatrist. Your GP needs to refer you to a psychiatrist. You do not need to see a psychologist before consulting with a psychiatrist.
Only complete if you are enquiring about ADHD assessment.

I understand that a psychiatrist consultation is required for ADHD medication to be considered and prescribed. I still want to enquire about ADHD assessment with Blanche.
NDIS considerations
- Blanche does not complete NDIS access request forms or address funding requirements in detail in reports.
- Blanche's assessments provide a diagnosis (including a 'level of support' for Autism assessments) and are not likely on their own to provide enough evidence of functional capacity for NDIS purposes.
- If you are wanting to use the diagnosis for NDIS purposes, please check directly with NDIS what you need before agreeing to assessment.
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.
Medicare Rebates and Private Health
- 25 year olds and over are not eligible for a Medicare rebate for assessments.
- Under 25 year olds may be eligible for a Medicare rebate for autism assessments. A referral is required by a psychiatrist or a paeditrican to access this rebate and must be obtained prior to beginning the assessment.
- Some private health funds may cover some of the cost of psychological assessment. You will need to check with your insurer prior to beginning the assessment.
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.
Mental health history
Please indicate any mental health diagnoses you have received:

Anxiety (ie worry, panic, social, phobia)DepressionTraumaSubstance misusePersonality disorderBipolarEating disorderSchizophreniaPsychosisOther - 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.
Medication
Please list medications you are prescribed and the reasons for taking.
Legal matters
Do you have any current legal matters in court? For example family law court, criminal matters.*

NoYes
If yes, please provide details:
Do you have current guardianship orders in place for making decisions? For example, someone else decides where you live, what services you engage with, how you spend your money, etc.*

No. I make my own decisions.Yes. I have a guardianship order in place.
Further information
Is there any further information you would like to provide?
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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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.
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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 Intake Form

Contact details

Assessment needs

Mental health history

Neurodevelopmental differences or brain injury

Medical conditions or illness

Medication

Legal matters

Further information

Existing reports or documents

Privacy Collection Statement