2026 Appointment Request Form

Thank you for choosing Action Psychology SA.

We are pleased to advise that we currently have capacity for both Autism Spectrum Disorder (ASD) assessments, Cognitive/Educational assessments and ADHD assessments with wait times currently sitting at approximately 2–3 months.

Unfortunately, due to reaching our current capacity for therapy appointments, we currently have a waitlist for ongoing therapy services.

If you would like to be added to our waitlist, please complete the form below. Your information will then be passed on to our Principal Psychologist, who will review the information provided and make a recommendation regarding which practitioner may be best suited to your circumstances.

We will then contact you when an appointment becomes available to discuss further details and confirm a suitable appointment time. At this stage, we are unable to provide a clear indication of current wait times, as these can vary depending on clinician availability and referral needs. However, we will do our best to arrange an appointment as soon as possible.

What service are you requesting?

Client Name

First NameLast Name

Preferred Name

DOB

Date

Pronouns

optional

Contact Number

Please enter a valid phone number.Format: 0000 000 000.

Email Address

Primary

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)

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

Do you have a Mental Heath Care Plan from a GP?

Please note: A Mental Health Care Plan will not cover the full cost of the session. It enables you to receive a partial rebate from Medicare. The current rebate is $98.37.

For more information regarding fees, please click here.

Do you have NDIS Funding?

Name of GP

Name of Practice

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

Were you referred to our practice by someone other then a GP?

Who referred you?

Name of referrer (optional):

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)

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):

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?

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