Child Pre-assessment Questionnaire

Psychology Assessment Request

Please complete the details below and we will contact you to discuss the assessment
Parent Name*

First NameLast Name
Contact Phone Number*

Area Code or first 2 digitsPhone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

SuburbState

Post CodeCountry
Child's Details
Child's Name*

First NameLast Name
Child's Date of Birth*

DayMonthYear
Date
School sector

PublicIndependentCatholic
Child's Year Level at School*
NOTE: Separated Families

Your psychologist is entitled to assume that you, the presenting parent, have parental responsibility, or are a legal guardian of the child participating in the assessment. A consent form will need to be signed by both parents before the assessment unless there are custody orders naming one parent as having sole parental responsibility or other exceptional circumstances apply. Please contact SPELD SA if you have any questions regarding this.
Preferred location for assessment *

Frewville (259 Glen Osmond Road)Online
How did you learn about SPELD SA?

SPELD SA websiteSocial MediaGoogle / Internet searchFriendSchoolOther
Submit Form

To submit the form online, you will need to enter the Captcha word below and then click the SUBMIT button. You will receive an email copy of the information you have provided for your records.
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Psychology Assessment Request