Child 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? *

Please fill out our Adult Assessment Enquiry Form here.

Are you a parent / legal guardian of the child? *

Do you have permission from the child's parent / legal guardian to fill out this form on their behalf? *

Please call Speld Qld on 07 3391 7900 to discuss.

You will be asked to supply this evidence of consent at a later stage of the booking process.

Child Details

Child's First Name *

Child's Last Name *

Date of Birth *

Day

Month

Year

Gender

What are your child's preferred pronouns?

School

Year Level *

Is your child 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 services for self-managed or plan-managed clients.

Assessment Information

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:

Has your child had extra help for their area of difficulty? (e.g., reading, spelling, structuring writing, maths) *One requirement for the diagnosis of a Specific Learning Disorder is that the individual has engaged in extra help or intervention for the specific area of difficulty.YesNoNot sure

Do you have any additional notes about the extra help or intervention?

Does your child have any existing diagnoses? (Click all that apply) *NoneAutism Spectrum Disorder (ASD)Attention Deficit/Hyperactivity Disorder (ADHD)Generalised AnxietyGlobal Developmental DelaySpeech / Language DisorderOther: Please specifyPrefer not to say

If other, please specify:

Has your child previously completed any assessments? *For example, a cognitive (IQ test e.g., WISC-V), learning assessment (e.g., WIAT-III), speech and language (e.g., CELF-5).

Who conducted this assessment?

When was the assessment completed?

Do you have any additional notes about the previous assessment?

How did your child meet their early developmental milestones? *EarlyAs ExpectedDelayedNot Sure

Do you have any additional notes about your child's developmental milestones?

Has your child experienced anything significant recently that you think has impacted their current wellbeing? *e.g. serious illness, family changes, loss, bullying.

Parent / Guardian Details

Parent First Name *

Parent Last Name *

Email Address *

Phone *

Street Address *

City

State/Province

Postal Code

Country

How did you hear about Speld Qld? *A friend - parent group, community groupSchoolSocial media - Facebook, Instagram, TwitterMedical professionalSearch Engines (Google, Bing)Government Website Education, HealthPrint mediaOther- please specity

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 projects *YesNo

I give consent for my child’s deidentified data to be used for research and evaluation purposes *YesNo

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Child Assessment Enquiry Form

Child Details

NDIS

Assessment Information

Parent / Guardian Details

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

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