Therapy

Assessment

Workplaces

Mental Health Education

Meet the Team

Therapy

Assessment

Workplaces

Mental Health Education

Meet the Team

Therapy

Assessment

Workplaces

Mental Health Education

Meet the Team

This form is for adults only - if you are submitting a referral as a parent or guardian, please use the parent’s referral form.

Psychological Assessment:
Adult Referral Form

You have been referred to Health in Mind Orange for a formal psychological assessment. In order to assist the Psychologist to understand the specific areas of concern, it would be appreciated if you could complete the below form prior to the assessment and return it to our office as soon as practical. This form may be completed by yourself or a carer who knows you well.

If you have a copy of results from any previous cognitive or psychological assessments for yourself, 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, Jodie Baalbergen, Mickalla Davis, Elissa Hiller, Grace McCormick and Isabel Harris. If you have any issue with this (e.g. you recognise a conflict of interest) please raise it with our administration team.

Name *

First Name

Last Name

Date of birth *

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Language(s) spoken *

This form has been completed by: *

Myself

My carer (please specify person/relationship below)

Other (please specify person/relationship below)

Name and relationship:

Reason for referral:

In the box below, please briefly outline your concerns about your academic, occupational and/or intellectual functioning and/or why an assessment is required. Alternatively, please choose from the answers below if applicable.

I am seeking an assessment for ADHD

I am seeking an assessment for autism

I am seeking an assessment for learning difficulties (e.g. dyslexia)

I am seeking an assessment for intellectual disability or cognitive impairment

I am not quite sure and would like a phone call to discuss my concerns

I am seeking a mental health assessment

Please choose up to five concerns you have that are relevant to this assessment: *

Reading comprehension and/or fluency

Language/speech

Writing (spelling and grammar)

Mathematics

Memory

Gross motor skills (e.g. clumsiness)

Fine motor skills (e.g. poor handwriting)

Depression or low mood

Work functioning/ability to work

Ability to learn new information

Organisation and planning

Following instructions

Attention and concentration

Impulse control

Self-care and hygiene

Aggression or anger

Anxiety or worrying

Sleeping problems

Problem solving and being flexible in new situations

Please rate the chosen five answers from 1 to 5 in order of priority for assessment: *

Relevant medical and psychological history: *

Please indicate if you have experienced any of the following difficulties: (select where appropriate)

Vision impairment or need for glasses

Hearing impairment or need for hearing aids

Physical impairment or mobility issues

Repeated a grade of school/has significant academic problems/enrolled in special education class at school

Poor social skills with peers or others

Suffered a head injury or loss of consciousness

Epilepsy

Complications at birth (i.e. born premature, caesarean, or other complications)

Did not develop language until later than normally expected (e.g. minimal language spoken at age 2-3 years)

Delayed onset of walking or crawling

Digestive issues/fussy eating/food intolerance

Diagnosis of ADHD (Attention Deficit Hyperactivity Disorder)

Diagnosis of ODD (Oppositional Defiance Disorder)

Diagnosis of Depression and/or Anxiety

Diagnosis of Autism or Asperger's

Previous history of abuse or neglect

Previous episode of Meningitis

Other relevant medical or psychological factors:

Current medications:

Current treating General Practitioner *

Current treating Occupational Therapist

Current treating Speech Therapist

Current treating Psychologist/Psychiatrist

Current treating Paediatrician

Important information: *

Please indicate your understanding of an agreement with the following items before proceeding with this referral. If there are any items you are unsure or concerned about, a member of the assessment team will contact you to discuss these further.

The approximate costs for an assessment range from $1200 (i.e. ADHD assessment) to $3000 (i.e. Autism assessment).

The assessment will not proceed until I have paid a deposit at the agreed amount (not applicable for NDIS funded assessments)

The assessment report will not be released until full payment of the assessment has been received.

Please tick any of the following optional statements that you agree with:

I can provide previous assessment reports completed by a psychologist or psychiatrist/occupational therapist/speech therapist or paediatrician

I can provide copies of school reports from primary school and high school.

I have a parent/caregiver or person who knew me well before the age of 12 years old who is available for an interview (ADHD assessments in particular).

I have a parent/caregiver or person who knew me well around the age of 4-5 years old who is available for an interview (Autism assessments only).

I am happy for a provisional psychologist to complete this assessment (supervised by a registered psychologist) and am aware that this will reduce the assessment cost to me.

Thank you!