Child Pre-assessment Questionnaire

Psychology Assessment Request

Please complete the details below and we will contact you to discuss the assessment.
Please note that SPELD SA provides a private assessment service and fees apply. If you have any questions, please contact us on (08) 8431 1655 and press 1 for assessment enquiries.
Parent Name

First NameLast Name
Contact Phone Number

Area Code or first 2 digitsPhone Number
Address

Street Address

Street Address Line 2

SuburbState

Post CodeCountry
Email
example@example.com
Child's Details
Child's Name

First NameLast Name
Child's Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
School sector
School attending
Child's Year Level at School
Please check all that apply
My child has received additional support or targeted intervention specifically for their learning difficulty, beyond general classroom teaching.
My child has shown persistent difficulties, meaning the learning difficulties have continued over time, despite usual classroom teaching and/or additional support?
Your child's psychologist will need evidence that the learning difficulties are persistent and not simply due to gaps in learning or insufficient instruction. Evidence of ongoing difficulties despite targeted intervention, including over a period of around six months, can help establish this and is important in supporting a potential diagnosis.
PARENTAL CONSENT

Your child's 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
How did you learn about SPELD SA?

Other
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Psychology Assessment Request