If you are enquiring about services for more than one family member/client, please complete a separate copy of this form for each individual.

Your Details

Your First Name *

Your Last Name *

Are you enquiring for yourself or on behalf of someone else? *

Myself

Someone else

If you are a parent enquiring for your child/dependent, please choose the option 'Someone Else'

If someone else, what is your relationship to the client? For example, parent, caregiver, guardian

Client Information

You could be enquiring on behalf of yourself, or on behalf of someone else, such as a child, dependent, client, or other. The following section is to share with us the details of the Client.

Client First Name *

Client Last Name *

Client Contact email *

Client Contact number *

Client Date of birth *

Client age (in years) *

How can we help?

If you are seeking therapy services, please tell us more about this. *If you are not seeking therapy services, please write "N/A"

Select all that may apply to your enquiry *

Mental Health Social Worker / Psychotherapist

Speech Pathologist / Mental Health Speech Pathologist

Psychologist / Clinical Psychologist / Family Psychologist

Occupational Therapist

Mentor Support Worker

Group Therapy Programs

Parenting Workshops and Programs

None of the above

Other

If you are seeking assessment services, what sort of assessment services are you seeking? *

Autism Assessment

ADHD Assessment

FASD Assessment

GDD Assessment

Cognitive/Intellectual Disability Assessment

Speech / Language Assessment

Functional Capacity Assessment

Psychological Assessment

Educational Assessment

Developmental Assessment

I'm not sure

Other

N/A - Not seeking assessment

If other, please provide more details

Referral Details

Do you have a referral from a GP, paediatrician, or psychiatrist? *

Yes

Not Applicable

If yes, please upload your referral

Is the referral specifically for a complex neurodevelopment disorder assessment? *

Yes

Not Applicable

How can we get in touch?

Email *

Contact number *

Please note that due to the high volume of enquiries our Client Care Team receives, it may take up to 3 business days for us to respond to your query.

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