Student Assessment Information Form

= Required Fields

Your Details

Who are you completing this form for?

Are you a parent / legal guardian of the child?

Child Details

First Name & Surname

Date of Birth

School

Year Level

Gender

Is your child of Aboriginal and / or Torres Strait Islander origin?

Additional Information

Please share you/your child’s pronouns?

Have you been referred to us by? (Click all that apply)

Note: No referral is needed to access Speld QLD's services

What assistance would you like? (Click all that apply)

Please note that additional assessment(s) may be recommended by the psychologist

Psychoeducational Assessment (cognitive ability/IQ and academic achievement to diagnose or rule out Dyslexia and other learning disorders)

Attention difficulties screener

Review Assessment (only available if full psychoeducational assessment completed at Speld within last 2 years)

Not sure

Do you have any additional notes about the assistance you require?

What are you hoping to get out of the assessment? (Click all that apply)

Does your child have any existing diagnoses that impact their learning? (Click all that apply)

Has your child previously completed a cognitive (IQ) and / or learning assessment?

If yes, who conducted this assessment?

If yes, when was the assessment completed?

How does your child feel about tests at school?

Has your child experienced anything significant recently that you think has impacted their current wellbeing?

e.g. serious illness, family changes, loss, bullying

Parent / Guardian Details

First Name

Surname

Mobile

Region

Street Address

Suburb

State

Postcode

Image Verification

Would you like to sign up for a Speld Membership?

Yes

Before submitting, please ensure your phone and email address are correct so we're able to contact you.

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Student Assessment Information Form

Your Details

Child Details

Additional Information

Parent / Guardian Details

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