2026 Appointment Request Form

We are pleased to announce that we have re-opened our waitlist are are available to take bookings with our provisional psychologists Carol, Lawrence and Heather. These are psychologists who have completed 5 years of university studies and are now in their final one year internship to become generally registered psychologists. They work under the supervision of a fully registered and board-approved psychologist within the practice.

Please have a look at our website where you can find information on our new practitioners. If you would like to be addedd to our wait list, complete the form below including as much relevant details about your needs as possible. Once completed our lead practitioner will then review the information and match clients with practitioners based on their presenting needs to ensure the best fit for support.

Once you have submitted the appointment form, you will be added to our waitlist for review and allocation.

Please be aware at this point in time it is only our provisional psychologists who have capacity for new clients.

What service are you requesting?*

PsychologyASD AssessmentCognitive AssessmentOther

Client Name*

First NameLast Name

Preferred Name

DOB*

Date

Pronouns

optional

Contact Number*

Area CodePhone Number

Email Address*

example@example.com

Address*

Street Address

Street Address Line 2

CityState

Post Code

Contact Details (if you are completing the form on a clients behalf)

First NameLast Name

Relation to Client

Are there any court orders that may be relevant to the services received at Action Psychology SA (details to be verified by a copy of the court order prior to commencement of session)*

YesNo

Please attach a copy below or email a copy to our admin team (admin@actionpsychologysa.net)

Do you have a referral, or has someone or an organisation referred you to our services?*

YesNo

Who provided the referal?

Name of Referrer

Optional

Please upload a copy of your referral if we do not currently have a copy:

Please list any medical information, including hearing, eyesight, allergies, diagnosed conditions and any medications taken that may be relevant to services being sought from Action Psychology SA

Do you or your child (if your child is the client) have a current diagnosis for any the following:*

Please upload a copy of any relevant reports relating to your diagnosis (you can also email the reports to admin@actionpsychologysa.net or drop off a copy at our practice)

To help us place you with the right clinician please list the main reason/s for requesting psychology*

Have you experience any Trauma? (eg: death, bereavement, illness, physical/emotional/sexual abuse)

If you do not have a Mental health Care Plan please select which best suits you?*

Private HealthNDISOther

Please list appointment day and time preference to assist us with booking your appointment? (Please keep in mind times are subject to availability)

Preferred Clinician (See our website for practitioner information)

What would you like to get out of therapy?

What are your expectations from your therapist?

Please list any other allied health services attended and provide reports if available

File Upload

Have you sought psychological services before for you mental health? If yes, please summarise (Eg hospitalisation. therapy etc):

YesNo

Please Summarise:

School Grade

Current School

Primary Language

Language Spoken at Home

Please provide a brief outline of the family and living arrangements of the individual being assessed:

Why are you looking to have an assessment done? Who suggested the assessment?

Please identify any previous assessments that have been conducted (E.g. cognitive, hearing, vision)

Please attach relevant teacher reports or concerns.

Our practice is a two-story building. Would you have any difficulty accessing the upstairs area if needed?

YesNo

Is there any further information you would like to add:

Appointment Request Form

Court Order

Referral Information

Medical Background

Reason for Requesting Psychology

Appointment Preferences

Previous/Current Allied Health Support

Information Required for Cognitive Assessment