Please copy this form onto a word page,  fill it in ( by hand or typed) and return it:

EITHER         scan and attach to an email to

OR                post a paper copy to 68 London Street, Richmond Christchurch 8013.

Any information you can tell us is helpful. The space will expand in a Word Document. Our goal is to phone you within 3 working days of receiving this information.

If you need help to fill in this form, please complete as much as possible then ring our receptionist. 

Thank you!


Name of the student or adult to be assessed _____________________________

Date of Birth __________  Present Age: ________    Gender:  Male/Female

Parent / Guardian: _______________________________________________

Address: ______________________________________________________

Phone: _____________ Work: ____________ Mobile: ___________________


Other Contact: __________________________________________________

Address: ______________________________________________________

Phone: __________________________ Mobile: _______________________

Present School: _____________________________________ Year: _______

What is your reason for requesting an assessment?________________________


What type of assessment do you require?______________________________


What is the area of concern? Please describe the concern where possible.





Any other area:________________________________________________

Have hearing & vision been tested – By whom and when? __________________

Has the person had any previous assessments or therapies? ________Yes/No__

(eg Occupational Therapy, General Intellectual Ability, Speech Language Therapy)? 

Please describe the previous assessments and therapies: what, when, by whom?


What has been done so far in the way of intervention? ( either at school or privately)


Does the person have a condition that would impact on a fair assessment?


The name of the person completing this form:___________________________

The account for assessments should be sent to:__________________________

Reports should be sent to (both parents/guardians named above are entitled to the report):