Sense Therapies Psychology Intake & Waitlist Form

** Please note that for children under 7 years old psychology appointments will be parent only and children will not have individual appointments. Sessions will focus on parent-based interventions for your child's presenting concerns.

Sense Psychology - Initial Appointment $465.98 *

Standard Ongoing Appointments : $232.99 p/hr Psychometric Assessment : $232.99p/hr (please note: Assessments may take up to 10-12 hours to complete)

Psychometric Assessments - further detail required. Please note that we DON'T do Autism Assessments.

Psychometric Assessments for: Specific Learning Disorders (Dyslexia, Dysgraphia, Dyscalculia)Psychometric Assessments for: Cognitive Ability (Intellectual disability, Giftedness, areas of strength and weakness)Psychometric Assessments for: Academic AbilityPsychometric Assessments for: ADHDPsychometric Assessments for: OTHER - please provide more detail below on the type of assessment you're seeking.

Psychometric Assessments for OTHER: More info

How did you hear about Sense Therapies? *

Participant First Name *

Participant Surname *

Participant D.O.B *

Pronouns

Address *

Street address *

City *

State *

Postcode *

PRIMARY Contact First Name *

PRIMARY Contact Surname *

PRIMARY Contact Relationship to Participant *

PRIMARY Contact Email Address *

PRIMARY Contact Mobile Number *

SECONDARY Contact Full Name *

SECONDARY Contact Relationship to the Participant *

SECONDARY Contact Email Address *

SECONDARY Contact Mobile *

What are the Participant's goals in relation to therapy *Attach copy of current NDIS Plan - if applicable (optional) - see end of this form

What would you like the Participant gain from partaking in therapy? e.g. socialisation, gross motor, emotional regulation, sensory processing skills etc *

Do we need to be aware of any risks? e.g. allergies, seizures, triggers etc *

Please specify any diagnoses, pre-existing &/or new injuries we need to consider in how we plan the sessions *

Is there anything the Participant would prefer NOT to partake in? *

Please attach any relevant documentation or reports.

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Email to send Invoices/Receipts to *

Payments *

NDIS Plan ManagedNDIS Self Managed Plan - 100% Payable on the dayPrivate Health Insurance - 100% Payable on the daySelf Funded/Out of Pocket - 100% Payable on the day

Name of Person Submitting this Form *

Contact Phone Number of Person Submitting this Form *

Signature of Person Submitting this Form *

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Date of Submission *