External Application for Psychological services

Expression of interest for Psychological Services
If you require an assessment service, please contact the office directly.

Psychology services are available by appointment only and are centre-based unless special circumstances warrant a home visit or school visit. Fees apply for a home/school-based service.

Please allow for the first consultation to be an information gathering session (unless this referral is for a formal assessment) before a treatment plan can be implemented.

ISADD sometimes offers a range of groups. These groups are run on a needs basis and are most beneficial when children can be grouped based on similar needs and abilities.

Please indicate the purpose of referral by ticking the most relevant box/es below.
ISADD Psychology Services acknowledges Aboriginal and Torres Strait Islander people as the Traditional Owners and Custodians of this land. We wish to acknowledge the strength of their continuing culture and offer our respects to the Elders of all lands.
Who is making this referral?*

Parent/CaregiverSelf ReferralOther
I have read and understood ISADD's Privacy and Confidentiality information. I agree to the conditions provided by ISADD.

Privacy Policy

Analytics

Like millions of other website owners, ISADD WA uses Google Analytics on our website. Google Analytics is a piece of software that grabs data about our site’s visitors. It logs non-personal information.

What does Google Analytics record? What website you came from to get here. How long you stay for. What kind of computer you’re using. And quite a bit more. What happens with the data? The tracking information allows us to better understand the kind of people who visit our site and what content they’re reading. This allows us to make better decisions about what content we should focus on or optimize for better interaction. Reports are created from this data, showing the behaviour of all of the visitors on our site. No personally identifying data is ever used.

For a more detailed explanation of the intricacies of this software’s privacy policy, visit http://www.google.com/analytics/tos.html. Want to opt out of tracking? If you would like to opt out of having Google Analytics at all, Google has made it easy by having their own plug-in do the work. Click here to opt out.

Privacy, Confidentiality, and Consent
By submitting this application, you consent to the collection, use, and disclosure of your personal information in accordance with the Privacy Act 1988 and the ISADD's Privacy and Confidentiality Policy. The information provided will be used for the purpose of processing your application and delivering supports and services. We are committed to maintaining the confidentiality of your personal information and will take all reasonable steps to ensure it is protected. You have the right to access, correct, and withdraw your consent for the use of your personal information at any time. We will only share your personal information with authorized parties when required for the delivery of services, or as required by law. If you have any questions about how your information will be handled, please contact us.

I have read the privacy, confidentiality and consent paragraph and consent to my information being obtained and used for the application of services.

Rights and Responsibilities of a Service Provider
As a service provider, we are committed to delivering high-quality, person-centered services in line with the NDIS Code of Conduct. We have the right to ensure that services are provided safely and effectively while maintaining clear communication with you regarding your goals, plans, and any changes in service delivery. Our responsibilities include respecting your dignity, privacy, and preferences, as well as ensuring that services are delivered in a timely and professional manner. We are also responsible for addressing any concerns or complaints you may have and providing appropriate support when needed.

I have read the rights and responsibilities of the provider, and should I have any further questions, I will raise them with the provider.
I agree to ISADD's Terms and Conditions*
Please select one of the following to indicate support required to complete this form*

I prefer to answer these questions in personI would prefer that an ISADD staff member to take down information via phoneI require an interpreter serviceI would like to choose my own interpreterI do not need support
Who referred you to the psychology service?

Medical practitionerSchoolFriendSelf referralOther
Name of person completing referral:*

First NameLast Name
Relationship to client:*
Phone Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Confirm Email Address
example@example.com
Which is your preffered method of contact?

PhoneEmail
Client Name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Preferred pronouns:

She/ HerHe / HimThey / ThemOtherOther
School/Employment status*

At school - Education supportAt school - MainstreamAt school - Ed support with integrationDoes not attend schoolHome schooledEmployedUnemployedAttends higher education (e.g. tafe, uni)Other
Funding:*

Private - MedicareCommonwealth Government National Disability Insurance Scheme (NDIS) fundingOther
If NDIS, please select who manages the plan:*

Agency ManagedSelf ManagedNominee ManagedPlan ManagedNot NDIS funded
If you have seen a psychologist previously, please list their name/s:
Services available:*

Cognitive Assessment - IQ testing using WPPSI, WISC, WAISFunctional Capacity Assessment (usually requested by NDIS)Behavioural Intervention planningIndividual counsellingParent counsellingSchool observation with follow up recommendationsDocumentation to support specific program entry e.g. letters of support to education department/government agencies, or entry into other services.Other documentation (fees may apply)GroupsOther
Issues for individual consultation:*

Emotion regulation specific to anxiety/stress/worry/specific phobiasEmotion regulation related to anger/opposition/defiance/aggressionTreatment or advice to treat rituals, OCD-like behaviour and/or inflexibilityTreatment plans for sleep disturbancesTreatment plans and/or advice for toileting issuesTreatment plans for eating issuesOther
Please describe issues/reasons for referral for individual consultation:*
Type of other documentation:

Carers allowanceCompanion cardVisa applications
Groups

Parent support group (mindfulness parenting program)Social Skills group
Any other information you feel is relevant:
Please upload any documents you feel may be useful to the psychologist

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Expression of interest for Psychological Services