Aspect Assessment Intake Form

This background information is being requested in order to help our staff and clinicians provide the best assessment for your needs. It will be used to determine the most appropriate clinician and to assist us prior to the assessment to prepare the most relevant tools and questions. All details provided here are used only to provide a broad overview prior to the assessment and they will be further discussed and clarified in the appointment.

Once we have received your completed form, our assessment team will be in touch within 4-5 weeks to book your appointment

If you any questions regarding this form, please call us on: 1800 277 328 or email: customerservice@aspect.org.au

This form should take approximately 10 minutes to complete.

Participant

Participant First Name *

Participant Last Name *

Date of Birth *

Gender *

FemaleMaleTheyOther

Please indicate preferred pronouns

If other, please indicate gender *

Email *

Mobile *

Street Address *

Street Address Line 2

City *

State *

Postcode *

Living Arrangements *

If other, please specify *

Do you identify as Aboriginal or Torres Strait Islander? *

YesNo

Please specify *

Enquirer Details

Who is completing this form? *

I am the participantI am enquiring on behalf of the participant

Enquirer First Name *

Enquirer Last Name *

Enquirer email *

Enquirer mobile number *

Relationship *

If Other, please specify the relationship to the particpant *

Who is the best person to contact? *

ParticipantEnquirer (the person completing this form)Other (please specify below)

Contact's first name *

Contact's last name *

Contact's email *

Contact's phone number *

What is the contact's relationship to the participant? *

Are you planning to use this assessment as part of a legal process? *

YesNo

Are there any Custody Orders in place? *

YesNo

If yes, please provide details *

Assessment Types and Costs

You can learn more about the different assessment types offered HERE.

Information about our current fees is available HERE

PLEASE NOTE: Full payment is required 7 days before the assessment appointment.

The NDIS does not typically fund diagnostic assessments. Medicare rebates are available to those under 25 years old who are referred by a paediatrician or psychiatrist. If you have private health insurance with extras cover, you may be able to claim a rebate through your health fund. Please contact your private health fund directly to see whether you are eligible for a rebate.

Please indicate what type of assessment and report (You can select more than one) *

Autism assessment - $2,650Review autism assessment - $2,650Cognitive or IQ assessment - $1,350

Cognitive (IQ) assessment cannot be offered via telehealth as it requires specific equipment, and must be done in a face-to-face context. All you need for a Telehealth Assessment is access to the internet and a computer or tablet (e.g., iPad) with a microphone and camera.

Confirm location of the assessment (You can select more than one) *

ChatswoodBaulkham HillsFar North Coast- Alstonville Telehealth (Autism or Review Assessments only)

Will anyone else be involved in the assessment process other than the client (e.g. parents, spouse) *

YesNo

Who else will be involved? *

Is this other person attending in person? *

YesNo

Please note we have clinicians who are able to conduct the assessment in Mandarin, Cantonese, and Tagalog and can arrange interpreters for other languages.

What is the main language spoken at home? *

Is an interpreter needed? *

YesNo

Assessment Information

Other Referrer, please specify *

Referrer's Name *

Referrer's Contact Number

Why has the assessment been requested? What information are you hoping to obtain ? What are your main concerns? *

If conducting for a child/teen, what will they know about the assessment?

Have there been any previous assessments (e.g. previous ASD, cognitive (IQ), speech etc)? *

YesNo

If yes please list them below *

Are there any previous diagnoses? *

YesNo

If yes, please list them *

Are there any additional support needs that the clinician will need to be aware of prior to the day? (you can select more than one) *

Please provide more details *

Preference for Female/Male Clinician *

FemaleMaleEither

Help us to get to know you or the individual better

What is the communication level? *

Nonverbal Single Words Phrases Fluent Speech

Are there any difficulties with comprehension? *

Please provide any interests *

Please provide any strengths *

Are there any concerns regarding intellectual capacity (i.e. IQ) or learning (eg dyslexia, math, etc.)? *

Are there any sensory needs or sensitivities? *

Anything else we should know?

By ticking this, I confirm that all information supplied at the time of completion is accurate *

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