By completing this form you are referring yourself to Health in Mind Orange for a formal psychological assessment. This form may be completed by yourself or a carer who knows you well.

Once submitted our administration team will be in contact.

If you have a copy of results from any previous cognitive or psychological assessments please also forward these to our office to assist the clinician.

Consent for information sharing: Please note that the information provided in your forms will be viewed by our cognitive assessment team for the purposes of allocating your assessment to a Clinician. These Clinicians are Nicole Sudmalis (Cognitive Assessment Team Leader), Debra Fidler, Mickalla Davis, Grace McCormick, Isabel Harris, Nick Leahy and Mitchell Wynne. If you have any issue with this (e.g. you recognise a conflict of interest) please raise it with our administration team.