External Application for Psychological services

Expression of interest for Psychological services
If you require an assessment service, please contact the office directly.

Psychology services are available by appointment only and are centre-based unless special circumstances warrant a home visit or school visit. Call-out fees apply for a home-based service.

Please allow for the first consultation to be an information gathering session (unless this referral is for a formal assessment) before a treatment plan can be implemented.

ISADD sometimes offers a range of groups. These groups are run on a needs basis and are most beneficial when children can be grouped based on similar needs and abilities.

Please indicate the purpose of referral by ticking the most relevant box/es below.
ISADD Psychology Services acknowledges Aboriginal and Torres Strait Islander people as the Traditional Owners and Custodians of this land. We wish to acknowledge the strength of their continuing culture and offer our respects to Elders past and present.
Who is making this referral?*

Parent/CaregiverSelf ReferralOther
Please select one of the following to indicate support required to complete this form

I prefer to answer these questions in personI require an interpreter serviceI would like to choose my own interpreterI do not need support
Who referred you to the psychology service?

Medical practitionerSchoolFriendSelf referralOther
Name of person completing referral:

First NameLast Name
Relationship to client:
Phone Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Confirm Email Address
example@example.com
Which is your preffered method of contact?

PhoneEmail
Client Name:

First NameLast Name
Date of Birth:

DayMonthYear
Date
Preferred pronouns:

She/ HerHe / HimThey / ThemOtherOther
School/Employment status*

At school - Education supportAt school - MainstreamAt school - Ed support with integrationDoes not attend schoolHome schooledEmployedUnemployedAttends higher education (e.g. tafe, uni)Other
Funding:*

Private - MedicareCommonwealth Government National Disability Insurance Scheme (NDIS) fundingOther
If NDIS, please select who manages the plan:*

Agency ManagedSelf ManagedNominee ManagedPlan ManagedNot NDIS funded
If you have seen a psychologist previously, please list their name/s:
Services available:*

Cognitive Assessment - IQ testing using WPPSI, WISC, WAISFunctional Capacity Assessment (usually requested by NDIS)Behavioural Intervention planningIndividual counsellingParent counsellingSchool observation with follow up recommendationsDocumentation to support specific program entry e.g. letters of support to education department/government agencies, or entry into other services.Other documentation (fees may apply)GroupsOther
Issues for individual consultation:*

Emotion regulation specific to anxiety/stress/worry/specific phobiasEmotion regulation related to anger/opposition/defiance/aggressionTreatment or advice to treat rituals, OCD-like behaviour and/or inflexibilityTreatment plans for sleep disturbancesTreatment plans and/or advice for toileting issuesTreatment plans for eating issuesOther
Please describe issues/reasons for referral for individual consultation:*
Type of other documentation:

Carers allowanceCompanion cardVisa applications
Groups

Parent support group (mindfulness parenting program)Social Skills group
Any other information you feel is relevant:
Please upload any documents you feel may be useful to the psychologist

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Expression of interest for Psychological services