Psychological Assessments

Attention Deficit Hyperactivity Disorder (ADHD)

A diagnostic assessment for Attention Deficit Hyperactivity Disorder (ADHD) is appropriate for children above six years, adolescents or adults with marked difficulties sustaining attention and/or hyperactivity and impulsivity.

This assessment includes:

• Clinical developmental history interview.
• Cognitive assessment, such as the WISC-V, A&NZ, and includes direct measures of processing speed and working memory.
• Administration of psychometric tools including the Conners-4 or Conners’ Adult ADHD Rating Scales (CAARS- 2), Conners Continuous Performance Test (CCPT), Executive Functioning scales, such as The Brown Executive Functioning and Attention Scales (Brown EF/A) and a series of neuropsychological assessments.
• Gathering of information from school reports, past reports, collaborative consultation with referring medical practitioners, and with consent, interview with educators to obtain observations from school/naturalistic settings.
• Scoring of results, interpretation and feedback consultation.
• Comprehensive diagnostic report.

Autism Spectrum Disorder (ASD)

Adults with marked difficulties with social-emotional reciprocity, nonverbal communicative behaviours, and the development and maintenance of relationships. As well as restricted repetitive behaviours including stereotyped motor movements, insistence on sameness, restricted interests, or hyper/hyperreactivity to sensory input.

This assessment includes:

• Clinical developmental history interview
• Use of ‘gold standard’ diagnostic tools, including the Autism Diagnostic Interview – Revised (ADI-R) or Autism Clinical Interview Adults (ACIA), and direct observational measures such as The Autism Diagnostic Observation Schedule 2nd Edition (ADOS-2).
• Gathering of information from school reports, past reports, collaborative consultation with referring medical practitioners, and with consent, interview with educators to obtain observations from school/naturalistic settings.
• Scoring and interpretation of results and a feedback consultation.
• Comprehensive diagnostic report.

Cognitive/ Educational Assessment

A Cognitive / Educational Assessment is appropriate for children, adolescents, or adults suspected of being academically gifted or having learning difficulties or a Specific Learning Disorder, with impairments in reading (Dyslexia), impairments in written expression (Dysgraphia) or with impairments in mathematics (Dyscalculia).

This assessment includes:

• Clinical developmental history interview
• Cognitive assessment including ONE of the following IQ tests:
• Wechsler Preschool and Primary Scale of Intelligence – Fourth Edition, Australian and New Zealand Standardised Edition (WPPSI-IV, A & NZ): Designed for young children ages 2 years 6 months up to 7 years 7 months.
• Wechsler Intelligence Scale for Children – Fifth Edition Australian and New Zealand Standardised Edition (WISC-V, A&NZ): Designed for school-aged children roughly 6 to 16 years old.
• Wechsler Adult Intelligence Scale -5 Australian and New Zealand Standardised Edition (WAIS-V, A&NZ): Designed for adolescents 16 and older (used when an IQ assessment is needed beyond the upper age limit of the WISC-V).
• Educational achievement testing including: The Wechsler Individual Achievement Test – Fourth Edition Australian and New Zealand Standardised Edition (WIAT-V, A&NZ): A comprehensive assessment used to evaluate a person’s academic skills in reading, writing, mathematics, and oral language. Designed for children aged 4 through to adults aged 50.
• Gathering of information from school reports, past reports, and collaborative consultation with referring medical practitioners, and with consent, interview with educators to obtain observations from school/naturalistic settings.
• Scoring and interpretation of results and a feedback consultation.
• Comprehensive diagnostic report.

Developmental Assessment and School Readiness

A Developmental Assessment is appropriate for children aged 1 month to 5 years and 11 months who are suspected of having developmental delay/s or if there is concern about school readiness.

This assessment includes:

• Clinical developmental history interview
• Administration of the Griffiths Mental Development Scales-Third Edition which measures five areas of development:
• Foundations of Learning
• Language and communication development
• Eye Hand Coordination
• Personal-social-emotional development
• Gross motor development
• Assessment of adaptive functioning (e.g., Vineland Adaptive Behavior Scales – Vineland-3 or Behaviour Assessment System for Children – BASC 3).
• Gathering of information from school reports, past reports, and collaborative consultation with referring medical practitioners, and with consent, interview with educators to obtain observations from school/naturalistic settings.
• Scoring and interpretation of results, and a feedback consultation.
• Comprehensive diagnostic report.

Intellectual Disabilities

This type of assessment is appropriate for individuals who have significant impairments in intellectual skills (like comprehension, reasoning, memory, and problem-solving) and adaptive behaviours (such as communication, self-care, and social skills) that began in childhood.

This assessment includes:

• Clinical developmental history interview
• Cognitive assessment including ONE of the following IQ tests:
• Wechsler Preschool and Primary Scale of Intelligence – Fourth Edition, Australian and New Zealand Standardised Edition (WPPSI-IV, A & NZ): Designed for young children ages 2 years 6 months up to 7 years 7 months.
• Wechsler Intelligence Scale for Children – Fifth Edition Australian and New Zealand Standardised Edition (WISC-V, A&NZ): Designed for school-aged children roughly 6 to 16 years old.
• Wechsler Adult Intelligence Scale -5 Australian and New Zealand Standardised Edition (WAIS-V, A&NZ): Designed for adolescents 16 and older (used when an IQ assessment is needed beyond the upper age limit of the WISC-V).
• Administration of adaptive functioning (e.g., Vineland Adaptive Behavior Scales – Vineland-3 or Behaviour Assessment Scale Children – BASC-3).
• Gathering of information from school reports, past reports, and collaborative consultation with referring medical practitioners, and with consent, interview with educators to obtain observations from school/naturalistic settings.
• Scoring and interpretation of results and a feedback consultation.
• Comprehensive diagnostic report.

Diagnostic tests used in the assessment process

As part of the assessment process Psychological Solutions Use of ‘gold standard’ diagnostic tools including
but not limited to:

• ADR-II Autism Diagnostic Interview – Revised (ADI-R) (3 Years +)
• ADOS-2  Autism Diagnostic Observation Schedule – 2^nd Edition (3 Years +)
• ACIA Autism Clinical Interview Adults (16 Years +)
• BASC Behaviour Assessment System for Children – 3rd Edition (2 to 21 Years 11 months)
• Brown EF/A Scales Brown Executive Functioning/ Attention Scales (3 Years +)
• CAARS-II Conners Adults ADHD Rating Scale – 2nd Edition (18+ Years)
• Conners-4 Conners Rating Scale – 4th Edition (6 to 18 Years)
• Conners K-CPT 2 Conners Kiddie Continuous Performance Test – 2nd Edition (4 to 7 Years 11 Months)
• DIVA-V Diagnostic Interview for ADHD in Adults – 3rd Edition (18+ Years)
• PAI Personality Assessment Inventory (18 – 89 Years)
• Sensory Profile 2 Sensory Profile 2 (0 – 14 Years)
• VABS-III Vineland Adaptive Behaviour Scales – 3rd Edition (0 to 90 Years)
• WAIS-IV Wechsler Adult Intelligence Scale – 4th Edition (16 to 85 Years)
• WIAT-III Wechsler Individual Achievement Test – 3rd Edition (4 to 50 Years)
• WISC-V Wechsler Intelligence Scale for Children – 5th Edition (6 to16 Years)
• WPPSI-IV Wechsler Preschool & Primary Scale of Intelligence – 4th Edition (2.5 to 7 Years)

Medicare

You might be eligible to claim for your psychologist consultation through Medicare.

People who can claim Medicare benefits include (but are not limited to):

• People with mental health disorders
• Children with an autism spectrum disorder(under 13 years for a diagnostic assessment; under 15 years for treatment)
• Children with a disability including sight impairment, hearing impairment, Cerebral palsy, Down syndrome and Fragile X syndrome (under 13 years for a diagnostic assessment; under 15 years for treatment)
• Women concerned about a current pregnancy, or one that occurred in the previous 12 months
• People who have a chronic medical condition and complex care needs
• Follow-up allied health services for people of Aboriginal or Torres Strait Islander

To be eligible to receive psychological services under Medicare, you must be referred by your GP or in some instances by a psychiatrist, paediatrician or consultant physician.

National Disability Insurance Scheme (NDIS) Psychology Services

Psychological Solutions™ offers NDIS-funded psychological therapy and assessments for adults, adolescents and children. We accept plan-managed and self-managed NDIS clients.

Psychological Solutions™ has psychologists who offer therapeutic support for NDIS participants. NDIS psychology services:

• Functional Assessments and Behaviour Support Plans
• Social and Emotional Skills Programs
• Emotion Regulation skills
• Respectful Relationship, Protective Behaviour and Consent Education Programs.
• Progress Review Assessments

Private Health Insurance

Contact your private health insurance provider to find out if they offer part rebates for psychological consultations.

To book an assessment complete the form below.

Assessment Referral and Intake Form

Consent

Show Form

Client Details

Client Full Name(Required)

Client Preferred Name(Required)

Client Pronouns

Client Date of Birth(Required)

DD slash MM slash YYYY

Client Residential Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Individual completing the form

(If not the client)

Client Contact Information

Name

(Specify if name of contact person is not the client)

Mobile(Required)

Email(Required)

Client Next of Kin/ Emergency Contact

Name(Required)

Relationship(Required)

Mobile(Required)

Parent/ Guardian Details #1

For clients under the age of 18

Name

DOB

DD slash MM slash YYYY

Contact Number

Email

Residential Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Parent/ Guardian Details #2

For clients under the age of 18

Name

DOB

DD slash MM slash YYYY

Contact Number

Email

Residential Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Background Information

In addition to this information, please include any school reports, previous assessment reports etc.

Assessment Type(Required)

Diagnostic Assessment

IQ & Educational Assessment

What questions do you hope to answer through this assessment?(Required)

Reason for referral/ main concerns(Required)

Please provide a short summary of the client’s situation/ background(Required)

Detail any strengths (e.g., skills, particular subjects, sport music social etc) and hobbies, activities or interests(Required)

Academic Information

Education Status(Required)

Currently studying

Not currently Studying

Education Provider Name(Required)

Current Education Level(Required)

Preschool

Primary school

High School

Tertiary

TAFE

Other

Year Level(Required)

Name of Course(Required)

Other(Required)

What kind of learning or development assistance (including learning support) has the client received, if any?

E.g., Speech and language therapy, OT, educational consultant, tutor, Reading Recovery, commercial program, etc.

Employment Information

Employment Status(Required)

Currently Employed

Not currently employed

Type of Employment(Required)

Full time

Part time

Casual

Contract

Other

Other(Required)

Employer(Required)

Position title(Required)

Psychology/ Psychiatry/ Medical History

Psychological History(Required)

e.g., past psychological interventions, past diagnoses, relevant medical/ psychiatric history

Previous Psychological/ Psychiatric/ Paediatric/ Speech and Language/ OT/ learning Assessment taken. Please provide findings from previous assessments (if applicable).

Vision – Has the client’s vision been tested? When and what were the results?(Required)

Hearing – Has the clients hearing been tested? When and what were the results?(Required)

Current medications – name, purpose, current dosage (if applicable)

Have you (the client) been hospitalised for mental health? If so, when and where?

Detail relevant family medical history(Required)

Is there an acute risk of suicide or self-harm to yourself (the client) that we should be aware of?(Required)

Is there an acute risk of physical harm to others that we should be aware of?(Required)

Medicare Information

Medicare Number(Required)

All numbers across the top of the card

Medicare IRN(Required)

Client number on card

Expiry date(Required)

Claimant

Applicable if the individual who is charged for the service is different to the client

Name

Medicare Number

All numbers across the top of the card

Medicare IRN

Client number on card

Expiry date

Other Funding Options (If applicable)

Are you an approved NDIS participant?

Other (e.g., Workers Compensation Insurance, Employee Assistance Program, PHN, Veterans)

Referral Information (If applicable)

Date

DD slash MM slash YYYY

Referral Type (if known):

Dr Name

Provider Number

Practice Name

Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Contact Number

Email Address

Consent

By consenting, I understand that all information in this form, and any previous forms (where applicable) including my personal information, will be collected for the primary purpose of delivering care; and for the ongoing monitoring, reporting, evaluation and improvement of services. I consent with the understanding that this information will only be used, disclosed and stored for its primary purpose, in accordance with the Australian Government Privacy Act, 1988.

Client Signature(Required)

Date

DD slash MM slash YYYY

Consent for Parent/ Guardian/ Carer (Clients under 18 years of age)

Parent/ Guardian/ Carer Name:

Signature

Date

DD slash MM slash YYYY