New Client Assessment Enquiry Submit the form below and a member of our team will contact you shortly Client's Name * First Name Last Name Date of Birth * MM DD YYYY Is client a minor? * Please note that we currently only provide assessments to clients aged 6 years and above. If you would like a referral for a child under 6, please contact our Client Support Team for details. Yes No Assessment being sought: ADHD Autism Combined ADHD/Autism Cognitive Assessment - to explore Intellectual Disability or IQ Other/Unsure Purpose for which the assessment is being sought Schooling Diagnosis Access Medication Access NDIS Increase NDIS funding Personal curiosity Other/Unsure Is client also interested in/in need for therapy in addition to an assessment? Yes No If client is a minor, contact persons name First Name Last Name Email * Home Phone (###) ### #### Mobile Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Your available days for appointments Monday Tuesday Wednesday Thursday Friday Saturday Your available times for appointments Early Mornings Morning Afternoon Evening Other Are you flexible? Yes No Which best describes your funding situation? Privately funded Medicare funded (MHCP) Private Health fund Third Party Other/Unsure If you are third part funded, are you funded by: NDIS WorkCover Employer Insurer Other/Unsure If you are on the NDIS, are you: Self-Managed Plan-Managed Agency-Managed Unsure If you are Plan-Managed, has your plan manager approved expenditure on this assessment? Yes No Unsure Are you currently on a waitlist for assessment elsewhere? Yes No If yes, Name of practice/practitioner and current estimated wait time Where did you hear about Evolve Wellbeing Psychology? Thank youA member of our team will be in touch with you shortly
