Please fill out the form below and we will get back to you as soon as possible with availability. Please note: any information you provide us will be kept confidential.

Name of Client *

First Name

Last Name

Date of birth *

Gender *

Pronouns *

Ethnicity *

Phone *

Email Address *

Name of Referring Person

First Name

Last Name

Relationship with client

Name of Referring Organisation

Contact details of Referring Person

I would like to consult regarding this tamariki or rangatahi prior to proceeding with referral.

Yes

Yes, however we add this client as potential referral to the waiting list.

Not required

Consent has been obtained to send through the referral. *

Yes

Clinical Services Required *

ADHD Assessment - Adult

ADHD Assessment - Child and Adoloscent

Autism Assessment

SAC - Special Assessment Conditions

FASD Assessment

Dyslexia (Specific Learning Disability) Assessment

Psychiatrist Consultation

Nurse Practitioner Consultation

Clinical Consultation and Follow up

Other

Region *

Please select which region the clinical assessment services is required in:

How can we help? *

Primary language spoken? *

Do you have any disability or access needs that we could support with?

Thank you!

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The Psychology Group proudly supports rainbow communities