Adult Assessment Information Form

= Required Fields

Your Details

Who are you completing this form for?

Client Details

First Name

Family Name

Date of Birth

Occupation

Gender

Phone

Region

Address

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

Additional Information

Please share your pronouns?

Have you been referred to us by? (Click all that apply)

Note: No referral is needed to access Speld QLD's services

What assistance would you like? (Click all that apply)

Psychoeducational Assessment (cognitive ability and academic achievement)

Attention difficulties screener

Intellectual Developmental Disorder Assessment (cognitive ability, academic achievement, adaptive functioning) formerly known as Intellectual Disability

Review 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)

A diagnosis (if appropriate)

A report detailing strengths and weaknesses

Guidance on how to help myself achieve my goals

Other: please specify

Not sure

Do you have any existing diagnoses? (Click all that apply)

Have you ever completed a cognitive (IQ) and / or learning assessment?

If yes, who conducted this assessment?

If yes, when was the assessment completed?

Image Verification

Would you like to sign up for a Speld Membership?

Yes

At times, Speld undertakes its own research to improve services and collaborates 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. You are free to say no, and this will not impact the services you receive at Speld in any way.

I give consent to being contacted about relevant research projects

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

How did you hear about Speld Qld?

Before submitting, please ensure your phone and email address are correct so we're able to contact you.

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Adult Assessment Information Form

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