By completing this form you are referring your child to Health in Mind Orange for the purposes of conducting a psychological assessment. To assist the Psychologist to understand the specific areas of concern, it would be appreciated if you could complete the below form and return it to our office as soon as practical.

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.