Adult Assessment Enquiry Form

If you would like help completing this form, please contact us on 07 3391 7900

Who are you completing this form for?

Client Details

First Name

Family Name

Date of Birth

Day

Month

Year

Occupation

Gender

What are your preferred pronouns?

Email *

Phone

Street Address *

City

State/Province

Postal Code

Country

Are you of Aboriginal and / or Torres Strait Islander origin?

NDIS

Are you planning to use NDIS funding?

NDIS Number

NDIS Plan Dates

Speld Qld is not a NDIS-registered provider and can only provide assessments for self-managed or plan-managed clients.

Assessment Information

Who have you been referred to us by? (Click all that apply)Please note: No referral is needed to access Speld Qld's services.School/WorkMedical PractitionerPsychologistSpeech PathologistOccupational TherapistOtherNot Applicable

If other, please specify:

What assistance would you like? (Click all that apply)Your assessor may recommend additional assessments.Psychoeducational Assessment (cognitive ability and academic achievement)ADHD & Psychoeducational AssessmentADHD AssessmentReview Assessment (only available if full psychoeducational assessment completed at Speld within last 2 years)Not sure

Do you have any additional notes about the assistance you require?

What are you hoping to get out of the assessment? (Click all that apply)Please note: A formal diagnosis is not guaranteed. However, every assessment is designed to provide valuable insight into an individual's unique strengths, challenges, and support needs.A diagnosis (if appropriate)A report detailing strengths and weaknessesGuidance on how to help myself achieve my goalsOther: please specifyNot sure

If other, please specify:

Do you have any existing diagnoses? (Click all that apply)NoneAutism Spectrum Disorder (ASD)Attention Deficit/Hyperactivity Disorder (ADHD)Generalised AnxietySpeech / Language DisorderOther: Please specifyPrefer not to say

If other, please specify:

Have you ever completed any assessments?For example, a cognitive assessment (IQ test e.g., WISC-V, WAIS-IV), learning assessment (e.g., WIAT-III), speech and language (e.g., CELF-5).

Who conducted this assessment?

When was the assessment completed?

If other, please specify:

At times, Speld conducts its own research to improve services and also works with external research institutions such as universities. To do this, we ask for your consent to contact you about relevant research opportunities and/or use deidentified client data. Saying no will not impact the services you receive at Speld.

I give consent to being contacted about relevant research projectsYesNo

I give consent for my/my child’s deidentified data to be used for research and evaluation purposesYesNo

Fill out this section if you would like to create a Guest Membership with Speld Qld.

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Adult Assessment Enquiry Form

Client Details

NDIS

Assessment Information

Fill out this section if you would like to create a Guest Membership with Speld Qld.

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