Referral Officer’s Assessment Form Referral OfficerReferral Officer Name(Required)SelectBelindaMelindaVanessaAmanda WrightToday'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)Person being assessed date of birth Month Day Year AgeSchool 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 Yes No Not Applicable Notes about response to 6 month intervention requirementIf the client is a school aged child and they have not had six months of intervention, the appropriate assessment is generally an Educational Assessment. If the client is an adult and they have not had intervention they can still completed the psycho-educational assessment as the psychologist can consider other diagnostic criteria.Has the parent been advised that diagnosis is unlikely to attract individual school based funding? Yes No n/a Testing Preference Assessment Type(Required) PAN – Psycho-educational Assessment of Numeracy PAL – Psycho-educational Assessment of Literacy PALN – Psycho-educational Assessment of Literacy and Numeracy EAN – Educational Assessment of Numeracy EAL – Educational Assessment of Literacy EALN – Educational Assessment of Literacy and Numeracy Diagnostic review Consultation Would the client like an ADHD assessment added to a Psycho-educational Assessment? Yes No Unsure The Educational Assessments are a new assessment type for SPELD NSW. They only include the Educational testing and DO NOT include a Cognitive Assessment. Students CANNOT get a diagnosis from an Educational Assessment. Educational Assessments are appropriate for students who haven’t had the 6 months intervention to help determine the specific areas of difficulty. Clients can come back after completing an Educational Assessment and after completing targeted intervention to complete a Diagnostic Review in order to be assessed for a diagnosis. Test Preference(Required) Face to face Online The SPELD NSW Clinic would prefer clients in Sydney complete a Face to Face Assessment. Online Assessment is available to clients in regional and rural areas and clients in Sydney who have disability or illness that makes it difficult to attend the SPELD NSW Office. 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 (2 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.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
