Psychological Assessment

Personal Information

Full Name:

Date of Birth:

Age:

Gender:

Pronouns:

Contact Number:

Email Address:

Address:

Referral Information

Referred By:

Date of Referral:

Assessment Requested:

Autism Assessment ADHD Assessment Psychosocial Assessment

Purpose:

NDIS Access Request NDIS Review NDIS Change of Circumstances

Report Preference:

Full Psychological Report Confirmation of Assessment Letter

Presenting Concerns

Main reasons for seeking assessment: How long have concerns been present? Previous assessments/interventions?

Yes No

If yes, details:

Psychological History

Previous evaluations: Diagnoses: Previous treatments & outcomes: Current medications:

Medical History

General health issues: Hospitalisations/surgeries: Medications:

Family Background

Who do you live with? Family history of mental health: Relevant family circumstances:

Educational & Occupational History

Highest education level:

Current occupation:

Currently studying?

Yes No

If yes, course:

Work-related stressors:

Social & Developmental History

Milestones met on time?

Yes No Unsure

If no, explain: Born full term?

Yes No

Pregnancy/birth complications: Friendships/community groups: Significant life events/traumas:

Consent to Psychological Assessment

I understand that I am being referred to at IGY6 Foundation for a psychological assessment.

I understand that:

The assessment may include interviews, observations, standardised questionnaires, and/or testing.
I have the right to ask questions and receive explanations about the assessment process.
Results will be discussed with me, and a written report or letter may be provided.
My information will remain confidential unless legally required.
I may withdraw consent at any time, noting this may impact the assessment process.

By signing below, I confirm that I understand and consent to the above.

Client Name:

Client Signature:

Date:

If the client is under 18 or has a legal guardian:

Parent/Guardian Name:

Relationship to Client:

Guardian Signature:

Date:

Psychological Assessment

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