Aspect Assessment Intake Form

***Aspect currently has availability for its assessments***

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 1-2 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 indicate what type of assessment and report (You can select more than one) *

Autism assessment - $3,150*Review autism assessment - $3,150*Cognitive or IQ assessment - $1,750* (cannot be offered via telehealth)ADHD (Attention Deficit Hyperactivity Disorder) assessment - $1,750* (for ages 5+yrs)

* Please note: A discount applies if the invoice is paid in full within 7 days of booking

All our psychologists are AHPRA registered psychologists with an area of endorsement (Clinical, Neuropsychology or Educational & Developmental) and qualified to conduct ADHD assessments. However, if you are wanting to access medications, you will need to consult a paediatrician/psychiatrist who may want to conduct further testing before prescribing medication.

For more information you can visit this site https://www.healthdirect.gov.au/attention-deficit-disorder-add-or-adhd

Please note that ALL assessments have a fee associated to them and this cost is not typically funded by the NDIS unless it’s been directly requested by the NDIA.

We always recommend you check with your Local Area Coordinator, Plan Manager or the NDIS directly.

A Medicare rebate is ONLY applicable to participants under the age of 25 and you MUST OBTAIN A REFERRAL from a paediatrician or psychiatrist to be eligible. This only applies to autism assessments, Medicare rebates are not available for cognitive and ADHD assessments.

Unfortunately we are not able to offer a fee reduction to health care card holders.

Full payment is due 7 days prior to the assessment date. You can pay in instalments as long as the final payment is 7 days prior to your appointment.

If you have any questions regarding fees associated with an assessment, please call our customer service team 1800 277 328.

Do you still wish to proceed with an Aspect Assessment? *

YesNo

Thank you for your interest in Aspect Assessments.

We suggest you contact the following organisations for assistance:

Autism Connect 1300 308 699 www.amaze.org.au
Disability Gateway 1800 643 787 www.disabilitygateway.gov.au
Find a Clinical Psychologist Australian Clinical Psychology Association

These sites are filled with valuable resources and have information and services to help you find the support you need and possibly lower cost alternatives.

If you have further questions, please call 1800 277 328 or email: customerservice@aspect.org.au

Assessment Location

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

Chatswood officeBaulkham Hills officeOr Telehealth/Online (Autism or Review Assessments only)

We receive cancellations at times and need to fill these appointments at short notice (sometimes within 24-48 hrs). Please tick the box below if you would like to be placed on our cancellation list.

Yes I would like to be placed on your cancellation list.

Please note you must be available at short notice and we can only offer the date of the cancelled appointment. You will receive a text message from Aspect with the date and location of the available appointment and will be asked to call 1800 277 328 to confirm the booking, as the appointment will be released to the first available caller.

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, and Cantonese 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?

This information is being collected for the purpose of determining service eligibility/provision and will be handled in accordance with Aspect’s Privacy of Personal Information and Data policy

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

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