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 our Advisory Team on 1800 371 085 or email us at support@speldsa.org.au
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
PublicIndependentCatholic
Child's Year Level at School*
Please note that in order to receive a diagnosis, the child must have received six months of extra support targeting the area of difficulty. If you are not sure if this has occured, please contact our Advisory Team to discuss: Free call 1800 371 085 Monday to Friday 9am-1pm or email us at support@speldsa.org.au

We can provide options for intervetion programs that can be run at home or put you in touch with a tutor.
Hearing and vision have been checkedAt least six months of evidence-based intervention has been providedMy child has not had an assessment with a psychologist in the previous 2 yearsI am the child's legal parent/guardian
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.
Frewville (259 Glen Osmond Road)Online
SPELD SA websiteSocial MediaGoogle / Internet searchFriendSchoolOther
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Psychology Assessment Request