Referral Officer’s Assessment 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(Required) Reasons for Assessment Why is the assessment required? Main concerns about learning, literacy, numeracy?(Required) Information About the Person Being Assessed Person Being Assessed's Name(Required) Age School Year / Further Study / Work Experience Previous Testing / Diagnosis Previous Assessments Cognitive Testing with School Counsellor or Psychologist Academic Testing in Literacy or Numeracy (in addition to classroom assessments) Speech & Language Assessment Occupational Therapist ADHD assessment by a paediatrician or psychologist Assessment for Autism Spectrum Disorder Additional Notes on Previous Testing / Diagnosis Intervention Has the person being assessed received intervention in these areas? Reading Spelling Written Expression (clarity or organisation of written expression, grammar, and punctuation) Mathematics Handwriting (mechanical aspects of handwriting) Speech & Language Additional Notes on InterventionHas the client been advised by SPELD NSW that 6 months of intervention is required in the area of difficulty for diagnosis(Required) Yes No Not Applicable Notes about response to 6 month intervention requirement Has the parent been advised that diagnosis is unlikely to attract individual school based funding? Yes No n/a Testing Preference Assessment Type(Required) FAN FAL FALN Diagnostic review Test Preference(Required) Face to face Online Next Steps to start booking process If client wants to proceed with assessment:(Required) Advise client they will receive an email within the next week with forms to complete Advise client that an assessment appointment can be booked once the completed paperwork has been returned to SPELD NSW Advise client about waiting times (4-6 months) Add a new contact under the client’s record in MemNet with a task for Admin (Heather) with the assessment type, online/face to face, name of person being assessed Other Notes or Queries for the SPELD NSW ClinicIf the client wants to proceed with a booking with SPELD NSW please submit this form and then create a task in MemNet allocated to Heather (Admin) to book an assessment.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
