Assessment Exploration Session Enquiry Form
Please complete this form (takes approx. 5 mins) to enquire about a one-off 60 minute session to ask any questions you may have about assessment.
Are you seeking an in-person or Telehealth session?
In-person Toowoomba QLD
Telehealth (video call)
Whichever is available soonest
Contact details
We will only contact you via your preferred method.
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
Gender
Please Select
Female
Male
Non-binary
Transgender
Gender fluid
Other
Other details
Pronouns
she/her
he/him
they/them
other
Other
Preferred contact method
*
Email
Phone call
SMS
Phone number
*
Please enter a valid phone number.
Format: (0400000000).
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
Suburb
State
Post code
*
Telehealth (video call)
In-person Toowoomba QLD
What assessment are you considering?
*
Autism + ADHD (adult)
Autism only (adult)
ADHD only (adult)
Other
Details if 'other'
Do you have specific questions about assessment you'd like to cover in the session?
For example, to
Legal matters
Do you have any current legal matters in court? For example family law court, criminal matters.
*
No
Yes
If yes, please provide details:
Room access needs:
I am able to access the consultation room via a flight of 15 stairs with a railing.
I require a ground-floor access option for my assessment.
How did you hear about NeuroAffirm Psychology?
Google search
Social Media
GP
Health professional
Friend
Existing client
Other
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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