Assessment Enquiry Form

Thank you for your assessment inquiry to The Middle Path Psychology Group, Berwick. On this link, there are several questions to be completed. This is part of the initial enquiry process for assessments. Once the form is submitted, the assessing psychologist will receive your responses and contact you.

CLIENT DETAILS (the person to be assessed):

If the person to be assessed is Under 18 years of age, please complete all details except the email address and mobile number. These two answers must be yours, as the parent/carer/third party.

First Name *

Last Name *

DOB *

Residential Address *

Email Address *

Mobile Number *

Referrer

If you have been referred or requested by a GP, paediatrician, psychiatrist, clinician, or teacher, for an assessment, please complete these details below. If you don't know some of the details, please leave blank and speak with your assessing psychologist.

Referrer Full Name

Clinic or Organisation of the Referrer

Referrer Contact Number

Referrer Email Address

Background Information

Why has this assessment been requested or recommended? *

If the person to be assessed has a mental health history, please provide their diagnoses and any prescribed medications

If you selected Other, please write who it is intended for

If there are further details you'd like to add, please write these down below before submitting

Afte you submit your responses, we will be in contact with you via phone or email to discuss the enquiry. If you have any past reports, feel free to email us on info@themiddlepath.com.au, and quote your name.