SPELD NSW Referral Officer’s Assessment Form - SPELD NSW

Supporting children and adults with specific learning difficulties

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SPELD NSW Referral Officer Assessment Intake Form

Referral Officer

MM slash DD slash YYYY

Contact Details

Information About the Person Being Assessed

Vision Impairment & Handedness

Vision Impairment
Handedness

Hearing Impairment & Medication

Hearing Impairment
Medication

Previous Testing / Diagnosis

Cognitive Testing
Was the child diagnosed with an intellectual disability
If Yes, specify degree
Other testing (speech pathologist, OT etc)
Academic Testing
Was the child diagnosed with a specific learning disorder
A) If Yes, in what areas?
B) If Yes, specify degree

Intervention

Reading Intervention

Has the person being assessed received Reading Intervention?(Required)
Reading Intervention Location

Spelling Intervention

Has the person being assessed received Spelling Intervention?(Required)
Spelling Intervention Location

Mathematics Intervention

Has the person being assessed received Mathematics Intervention?(Required)
Mathematics Intervention Location

Writing Expression Intervention

(Written Expression refers to clarity or organisation of written expression, grammar, and punctuation NOT mechanics of handwriting. Please include notes about Handwriting Intervention below.)
Has the person being assessed received Written Expression Intervention?(Required)
Written Expression Intervention Location
If the parent/client is more concerned about the mechanical aspects of handwriting, such as pencil grasp, handwriting speed, and legibility (i.e. letter formation, line placement, sizing, and spacing), then an occupational therapy assessment would be more suitable.
Intervention – Has the client been advised by SPELD NSW that 6 months of intervention is required for diagnosis(Required)

Reasons for Assessment

Has the parent been advised that diagnosis is unlikely to attract individual school based funding?

Testing Preference

Client advised of assessment type, costs, length(Required)
Client advised about waitlist(Required)
Client advised that assessment appointment will not be booked until all paperwork is provided (an email with forms to complete will be sent to them)(Required)
Assessment Type(Required)
Test Preference(Required)

Online Assessments Only – Pre-screening questions

Is there a well-lit and distraction-free space in the house where the assessment can be completed?
Based on the parent's knowledge about their child’s behaviour and work habits, do they think their child will be able to handle online testing? / Does the adult being assessed think they will be able to cope with online testing?
If No to above 2 questions
What device will the child use?

Next Steps to start booking process

If client wants to proceed with assessment:
This field is for validation purposes and should be left unchanged.
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