Assessment Intake Form

Assessment Intake Form

Thank you for choosing Invisible Illnesses Inc. From Struggle to Strength: Inspiring Hearts, Igniting Hope. This form is for clients requesting one or more assessments. Assessment Fees: Each assessment is charged separately. Assessment Fee: $1,200 per assessment. Non-Refundable Booking Deposit: $200 per assessment. The $200 non-refundable booking deposit is required for each assessment selected and will be deducted from the total cost of that assessment. Examples: 1 Assessment = $1,200 total | $200 deposit | $1,000 remaining; 2 Assessments = $2,400 total | $400 deposit | $2,000 remaining; 3 Assessments = $3,600 total | $600 deposit | $3,000 remaining. Your assessment booking is not confirmed until your intake has been reviewed and the required deposit has been received.
Personal Details
Full Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Residential Address

Street Address

Street Address Line 2
SuburbState Post Code
Preferred Contact Method
Doctor's Name
Practice Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Is this appointment for yourself or someone else
Teachers Email Address
If applicable please provide the teacher's Email address
Birthdate of person being assessed

MonthDayYear
Date
Would you like your report sent to your GP?
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Intake Information
What has led you to seek an assessment?
Have you previously had an assessment?
Is there anything else you would like our team to know?
Have you used our services before
Are you currently receiving any support services elsewhere?
If yes please provide details
Are you a financial member?
Are you on any Centrelink Benefits
Do you get NDIS
Upload Documents
Referral Letter

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Previous Reports

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Medical Documents

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Other Relevant Documents

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Assessment Agreement
I understand each assessment costs $1,200.
I understand the $1,200 fee is charged per assessment, not per form submission.
I understand a non-refundable booking deposit of $200 is required for each assessment selected.
I understand the $200 deposit is charged per assessment.
I understand the deposit paid for each assessment will be deducted from that assessment's total fee.
I understand selecting multiple assessments requires a separate $200 non-refundable deposit for each assessment.
I understand the remaining balance is $1,000 per assessment.
I understand the remaining balance must be paid 14 days after my appointment or before my assessment report is released if a payment arrangement has been made.
I understand my booking is not confirmed until my intake has been reviewed and the required deposit has been received.
I understand the booking deposit is non-refundable if I cancel, fail to attend or choose not to proceed with my assessment.
I understand that if Invisible Illnesses Inc. is unable to provide the requested assessment service, the deposit paid for that assessment will be refunded in full.
I consent to Invisible Illnesses Inc. collecting and securely storing my information for assessment, administration and service delivery purposes.
Payment
Assessment(s) to book
Total Booking Deposit

Booking deposit

Adult Autism Assessment Booking Deposit

Deposit for Adult Autism Assessment

$200.00 AUD

ADHD Assessment Booking Deposit

Deposit for ADHD Assessment

$200.00 AUD

PTSD Assessment Booking Deposit

Deposit for PTSD Assessment

$200.00 AUD

Total

Payment Methods

Credit Card

Apple Pay

I consent to the collection and use of my personal information for the purposes of receiving services from Invisible Illnesses Inc.
Should be Empty:

Assessment Intake Form

Personal Details

Emergency Contact

Intake Information

Upload Documents

Assessment Agreement

Payment

Booking deposit*

Payment Methods

Booking deposit