Hopscotch & Harmony - Assessment Booking
We offer assessments at our Werribee and Belmont clinics and currently have immediate availability for most assessment types. Initial and feedback sessions can be held via Telehealth if that suits you. Once you submit this form, you will receive a personalised quote by email within two days.
Your Full Name
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Email Address
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Contact Number
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Can we leave a message on your mobile?
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Yes
No
What is your relationship to the person being assessed?
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I am the person to be assessed
Parent of a child under 18 years
Parent of an adult over 18 years
Guardian
Third Party funding the assessment
Other
Third Parties
Except in unusual circumstances, we will only make appointments directly with the client or parent/guardian. For third-party funded assessments, any late cancellation fees will be charged to the third party.
Who is responsible for accepting the quote and paying for the assessment (including any late cancellation or non-attendance fees)? Please give the details that need to appear on the quote/invoice
Does the child's guardian know that you are completing this form and that we might contact them?
Yes
No
Name of child's guardian:
Email of the child's guardian:
Phone number of child's guardian:
Adult client
If enquiring for someone else, please provide the client's contact details below. For ADHD assessments: We provide diagnosis and therapeutic strategies but cannot prescribe medication - ask your GP to refer you to a psychiatrist for medication management. For Autism assessments seeking NDIS funding: A psychiatrist or paediatrician must also be involved to meet NDIS requirements.
Date of Birth
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Month
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Day
Year
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Client's Email Address
Client's Phone Number
Gender and Pronouns
Language Spoken at Home
Child's details
First Name
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Surname
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Age
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Date of Birth
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Month
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Day
Year
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Kinder/School attending
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Language Ability
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Speaks fluently in sentences
Phrases
Single words
Non-verbal
Minimally verbal - Selective Mutism or intermittent communication
Speaks English as a second language
What are the child's living arrangements?
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Full time with both parents in the same house
Time is split between parents in different houses
Child lives with one parent but has contact with non-resident parent
Sole parent - there is no other parent involved
Other
Parental Acknowledgement Required
We will take reasonable steps to notify both parents or guardians that Hopscotch and Harmony is providing a psychology service to your child. If we become aware that one parent does not consent, we will not commence services. If consent is withdrawn after services have begun, we will discontinue services. We require the other parent’s contact details so we can email, and if needed phone, to advise that a referral has been made. If we do not receive an objection within three days, we will proceed with scheduling. Please discuss this with the other parent before submitting the form.
Are both parents/guardians aware and supportive of the child receiving our assistance?
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Yes
No
Do you have contact details for the other parent so we can notify them that an assessment referral has been made?
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Yes
No
Second parent contact details
Please provide details for the second parent so we can notify them that an assessment referral has been made.
Second parent's name
First Name
Last Name
Phone number:
*
Email address:
*
No contact details for the other parent
If you believe that there are extenuating circumstances as to why the other parent shouldn't be contacted, please provide them.
Court Orders
Are there court orders in place relating to the child?
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No
Yes, and I understand that Hopscotch & Harmony are bound by the terms of these orderes and cannot proceed without a copy.
Assessment Type
Which Assessment are you seeking? (choose one or more)
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Autism - Child aged 2 or 3 years ($2,100)
Autism - Child aged 4 - 17 years ($2,840, includes cognitive assessment)
Autism - Child aged 4 - 17 years ($2,100, ONLY if cognitive assessment has been completed within the last 2 years)
Autism - Adult ($2,490)
Autism and ADHD - Child ($3,170)
Autism and ADHD - Adult ($2,690)
ADHD - 6 to Adult ($2,490)
Learning Difficulties: Cognitive and Educational assessment ($2,695)
Cognitive (IQ) - 2.5 to 3years ($990)
Cognitive (IQ) - 4 years to Adult ($1,440)
Intellectual Disability (Cognitive & Adaptive Behaviour) - 4 yrs to Adult ($1,690)
Educational (reading, spelling, writing, maths) - 4 years to Adult ($1550)
Comprehensive Assessment - Autism, ADHD, Cognitive and Educational ($4,175)
Discovery Session (learn more about next steps and brief summary letter) - $390
Where would you like the assessment to take place?
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Werribee
Belmont
Either location - first available time is preferred
Referral
Do you have a referral for this assessment?
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Yes
No
Please share your referral with us
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My doctor has faxed my referral to you
I will email my referral to admin@hopscotchandharmony.com.au
I have already emailed my referral to admin@hopscotchandharmony.com.au
I do not have a referral
Previous Assessments
Please indicate if there have been previous assessments completed:
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Cognitive assessment (IQ test)
Speech Pathology assessment
Educational assessment (reading, writing, maths)
Autism assessment
ADHD assessment
No other assessments
If you indicated that previous assessments have been completed, when was each one completed? This will help us provide an accurate assessment quote. We will also ask you to provide these assessment reports should you proceed.
Is there a relevant diagnosis that you would like to share with us?
Please briefly describe what led you to seek this assessment and what you hope to achieve from the assessment (e.g., personal understanding, NDIS funding, educational funding, recommendations)
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Anything else important for us to know?
Funding and Rebates
Please note: In most cases NDIS will not approve funding for diagnostic assessments. A rebate of $98.95 (as of July 1st, 2025) may be available for the client-attended Autism assessment appointments. No other assessments attract a Medicare rebate. If you wish to claim against private health insurance, speak to your insurer for coverage information.
How will the assessment be funded?
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I will pay privately
NDIS - Plan Managed
NDIS - Self-managed (you will pay privately before the sessions and be provided your paid invoice after the service has been provided for you to claim back)
I am a third party completing this and my organisation will fund the assessment after we've approved the quote
Other
NDIS Details
What is the participant's NDIS Number?
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What is the name of the Plan Manager?
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What is the phone number of the Plan Manager?
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What is the contact email address of the Plan Manager?
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If there is a different email for invoicing please write it here:
Submit
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