Contact Us

Name *

First Name

Last Name

Client Name

If different from name of the person completing this form (i.e. you are the parent and your child is the prospective client)

First Name

Last Name

Client date of birth *

MM

DD

YYYY

Assessment *

What would you like to be assessed for?

Autism

ADHD

Intellectual Disability

Learning Disorder (Dyslexia, Dyscalculia, Dysgraphia)

I'm not sure

N/A - Not seeking assessment

Referral Info *

Do you have a referral from you paediatrician or psychiatrist?

Yes

No

Not Applicable

Preferred location *

At which location would you prefer to attend sessions?

North Perth only

Fremantle only

North Perth or Fremantle

Melbourne

Online (Telehealth)