Referral Officer SPELD NSW Referral Officer Assessment Intake Form Referral OfficerReferral Officer Name(Required)SelectBelindaMelindaVanessaToday's Date(Required) MM slash DD slash YYYY Contact Details Parent / Guardian / Adult being assessed Name(Required) Memnet Code Street Address Suburb and Postcode Information About the Person Being Assessed Person Being Assessed's Name(Required) Person Being Assessed's Date of Birth(Required) School Year Age School / University / Tafe / Workplace etc Vision Impairment & HandednessVision Impairment Yes No Vision Corrected With Handedness Left Right Hearing Impairment & MedicationHearing Impairment Yes No Hearing Corrected With Medication Yes No Medication Type Previous Testing / Diagnosis Cognitive Testing Yes No If Yes, when? Was the child diagnosed with an intellectual disability Yes No If Yes, specify degree Mild Moderate Severe Unsure Other testing (speech pathologist, OT etc) Yes No What type of other testing & when was it completed? Academic Testing Yes No If Yes, when? Was the child diagnosed with a specific learning disorder No Yes (if yes answer A & B) A) If Yes, in what areas? Reading Written Expression Spelling Maths Unsure B) If Yes, specify degree Mild Moderate Severe Other Recommendations from testingAdditional Notes on Previous Testing / Diagnosis Intervention Reading Intervention Has the person being assessed received Reading Intervention?(Required) Yes (specify frequency, length, type below) No Unsure No concerns about reading Reading Intervention - Specify frequency, length, when commenced and type Reading Intervention Location At school External Generalist Tutor Professional Tutor Other Spelling Intervention Has the person being assessed received Spelling Intervention?(Required) Yes (specify frequency, length, type below) No Unsure No concerns about spelling Spelling Intervention - Specify frequency, length, when commenced and type Spelling Intervention Location At school External Generalist Tutor Professional Tutor Other Mathematics Intervention Has the person being assessed received Mathematics Intervention?(Required) Yes (specify frequency, length, type below) No Unsure No concerns about mathematics Mathematics Intervention - Specify frequency, length, when commenced and type Mathematics Intervention Location At school External Generalist Tutor Professional Tutor Other 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) Yes (specify frequency, length, type below) No Unsure No concerns about written composition Written Expression Interventions - Specify frequency, length, when commenced and type Written Expression Intervention Location At school External Generalist Tutor Professional Tutor Other 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) Yes No Not Applicable Response to 6 month intervention requirement Additional Notes on Intervention Reasons for Assessment Why is the assessment required?Parents main concerns about child's learning / Adult being assessed's main concern about their learningHas the parent been advised that diagnosis is unlikely to attract individual school based funding? Yes No n/a Testing Preference Client advised of assessment type, costs, length(Required) Yes No Email parent Psychological Assessments Information Sheet Client advised about waitlist(Required) Yes No 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) Yes No Assessment Type(Required) FAN FAL FALN Full assessment Diagnostic review Test Preference(Required) Face to face Online Either Online Assessments Only - Pre-screening questionsIs there a well-lit and distraction-free space in the house where the assessment can be completed? Yes No 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? Yes No If No to above 2 questions Advise parent online format is not suitable What device will the child use? Tablet / ipad Laptop Desktop Next Steps to start booking process If client wants to proceed with assessment: Advise client they will receive an email within the next week with forms to complete Send Heather (Admin) a task in MemNet specify assessment format and assessment type. If you are not sure about assessment type please note that below and in the MemNet task and one of the psychologists will speak to the client prior to booking. Other NotesCAPTCHANameThis field is for validation purposes and should be left unchanged.
