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 firstname.lastname@example.org.
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 recpetionist.
Name of the student or adult to be assessed _____________________________
Date of Birth __________ Present Age: ________ Gender: Male/Female
Parent / Guardian: _______________________________________________
Phone: _____________ Work: ____________ Mobile: ___________________
Other Contact: __________________________________________________
Phone: __________________________ Mobile: _______________________
Present School: _____________________________________ Year: _______
What is your reson 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):