New Patient Intake Questionnaire - Assessments

Personal information provided on this form will be discussed and shared among agreed members of the Marsden Clinical Psychology (MCP) team. This may include psychologists, therapy assistants and administration staff. Information will be retained and kept confidential. No information will be shared without further permission from the individual / parent / carer.

To ensure we direct you to the most appropriate service and clinician, it is essential for us to gather detailed information about the individual seeking the assessment. Please respond to all the questions.

General Information

First Name *

Last Name *

Date of Birth *

Age *

If patient is a child, name of contact and the status of your relationship (parent, carer, guardian)

Email Address *

Phone Number *

Home Address *

Do you have NDIS funding? *

YesNoCurrently applying / awaiting approval

A note about NDIS: If you intend to use NDIS funding, please let us know now so we can organise the paperwork PRIOR to your appointment. If your NDIS paperwork is not finalised before your appointment, payment via EFTPOS/credit card will be expected on the day of service.

What are you hoping to get out of this assessment? *

Does the individual have any significant medical problems or diagnoses? *

Does the individual experience any hearing or visual difficulties? If so, have these been assessed, what were the results? *

Please provide some information on the individuals growth history. For example, birth weight and length, growth charts, current height and weight, recent changes in weight. *

Does the individual have any family history of suspected or diagnosed developmental or mental health conditions (e.g., ADHD, autism, depression, anxiety, learning disorder)? *

If the individual is a child, which school / grade are the enrolled in?

Does the individual have any history of trauma? *

Does the invididual take regular medication? *

YesNoNot currently, but has in the past

If you selected yes to the previous question, please list the name of the medication/s and reason it is prescribed.

Please provide any other information you think we should be aware of. This includes details of any legal or personal risk factors (e.g. patient is in out of home care, court proceedings, risk of self harm, suicide ideation, DCJ or police involvement)

Concerns and Assessment Details

In this section, please indicate the current concerns you have / you have for your child. This will help us identify areas of strength as well as challenges and how much they affect day to day life.

We understand that no two days are the same. If you can, base your response on an average day during the last month - not the worst nor the best.

Communication

Communication encompasses the ability to convey and understand information through spoken, written or sign language, as well as expressing needs and wants through gestures, speech, or contextual cues appropriate to ones age. It also includes the ability to engage in social communication and to understand and follow instructions.

How much of a concern is this? *

Not at allSomewhatVery much

Is this something you would like us to assess? If you select yes, please explain why in the next question. *

YesNo

More information (please elaborate here if you have indicated that communication is an area of concern)

Has 'communication' been assessed before? (e.g. speech therapy/assessment, psychology sessions/assessment) *

Yes, I have a report/letter I can share with youNo, this needs to be assessedNo, this is not an area of concern at this time

Date of previous assessment?

Social Interaction

Social interaction involves forming and maintaining friendships (or playing with peers), engaging with the community, adhering to social norms and boundaries, and managing feelings and emotions in social situations.

Is this something you would us to assess? If you select yes, please explain why in the next question. *

YesNo

How much of a concern is this? *

NoneSomewhat Very Much

More information (please elaborate here if you have indicated that social interaction is an area of concern)

Has 'social interaction' been assessed before? (e.g. speech therapy/assessment, psychology sessions/assessment) *

Yes, I have a report/letter I can share with youNo, this needs to be assessedNo, this is not an area of concern at this time

Date of previous assessment?

Attention and Executive Functions

Attention and executive functions encompass the ability to concentrate on less-preferred or complex tasks, manage an active mind and body, organise thoughts and belongings, as well as address forgetfulness and procrastination.

Is this something you would us to assess? If you select yes, please explain why in the next question. *

YesNo

How much of a concern is this? *

Not at allSomewhatVery much

More information (please elaborate here if you have indicated that attention and focus is an area of concern)

Has 'attention and executive function' been assessed before? (e.g. cognitive assessment, educational assessment) *

Yes, I have a report/letter I can share with youNo, this needs to be assessedNo, this is not an area of concern at this time

Date of previous assessment?

Academic skills

Academic skills involve keeping pace with peers in reading, writing, and math, as well as grasping fundamental concepts.

Is this something you would us to assess? If you select yes, please explain why in the next question. *

YesNo

How much of a concern is this? *

Not at allSomewhatVery much

More information (please elaborate here if you have indicated that academic skills is an area of concern)

Have 'academic skills' been assessed before? (e.g. cognitive assessment, educational assessment)

Yes, I have a report/letter I can share with youNo, this needs to be assessedNo, this is not an area of concern at this time

Date of previous assessment?

Daily living skills

Daily living skills encompass activities related to personal care, such as hygiene, grooming, and self-feeding, including showering, bathing, dressing, eating, toileting, and attending to health needs. These skills also involve cognitive abilities necessary for organising one’s life, planning, decision-making, and self-management. This includes completing daily tasks, solving problems, and managing finances.

Is this something you would us to assess? If you select yes, please explain why in the next question. *

YesNo

How much of a concern is this? *

Not at allSomewhatVery much

More information (please elaborate here if you have indicated that daily living skills is an area of concern)

Have 'daily living skills' been assessed before? (e.g. occupational therapy assessment/sessions) *

Yes, I have a report/letter I can share with youNo, this needs to be assessedNo, this is not an area of concern at this time

Date of previous assessment?

Mobility

This means the ability of a person to move around the home (crawling or walking) to undertake ordinary activities of daily living, getting in and out of bed or a chair, leaving the home, moving about in the community and performing other tasks requiring the use of limbs.

Is this something you would us to assess? If you select yes, please explain why in the next question. *

YesNo

How much of a concern is this? *

Not at allSomewhatVery much

More information (please elaborate here if you have indicated that mobility is an area of concern)

Has 'mobility' been assessed before? (e.g. occupational therapy assessment/sessions) *

Yes, I have a report/letter I can share with youNo, this needs to be assessedNo, this is not an area of concern at this time

Date of previous assessment?

Emotional management

This means the cognitive and emotional capacity to understand, regulate, and respond to one's own emotions and mental well-being. This involves recognising and managing a wide range of emotions, coping with stressors, maintaining resilience, and fostering positive mental health habits.

Is this something you would us to assess? If you select yes, please explain why in the next question. *

YesNo

How much of a concern is this? *

Not at allSomewhatVery much

More information (please elaborate here if you have indicated that emotional management is an area of concern)

Has 'emotional management' been assessed before? (e.g. cognitive assessment, psychology assessment/sessions) *

Yes, I have a report/letter I can share with youNo, this needs to be assessedNo, this is not an area of concern at this time

Date of previous assessment?

Sensory Processing

This means the cognitive ability to effectively interpret and respond to sensory information from the environment. This includes processing input from the five senses (sight, hearing, touch, taste, and smell) as well as internal sensations (such as proprioception and vestibular input).

Is this something you would us to assess? If you select yes, please explain why in the next question. *

YesNo

How much of a concern is this? *

Not at allSomewhatVery much

More information (please elaborate here if you have indicated that sensory processing is an area of concern)

Has 'sensory processing' been assessed before? (e.g. occupational therapy assessment/sessions) *

Yes, I have a report/letter I can share with youNo, this needs to be assessedNo, this is not an area of concern at this time

Date of previous assessment?

Other providers involved in your / your child's care

Any other providers or contacts we should be aware of:

If you have given consent for us to contact any of the above providers, please provider their contact details here (name, phone number, email)

Thank you for completing this questionnaire. Once your form is submited, our clinical team will review it and be in touch to discuss available options and appointment times.