Appointment form for Assessments & Anxiety Programs

1. Your name *

First

Last

2. Email *

3. Telephone *

4. Name of child *

First

Last

5. Child's date of birth *

6. Your relationship to the child *

7. Are you a legal guardian for this child? *

Yes (please go to question 11)
No (please go to question 8)

8. Legal Guardian 1: Name (if you are not a guardian)

First

Last

9. Legal Guardian 1: Email (if you are not a guardian)

10. Legal Guardian 1: Telephone (if you are not a guardian)

11. To the best of your knowledge, is there any other legal guardian?

Yes (please provide their details in the next section)
No (please go to question 15)

(NOTE: If making a referral on behalf of a minor both legal guardians will be contacted to inform them about the service being made available and seek their consent for service delivery. Please inform us if there are there any court ordered guardianship agreements in place or a parent is deceased).

12. Legal Guardian 2: Name

First

Last

13. Legal Guardian 2: Email

14. Legal Guardian 2: Telephone

15. Are you interested in:

Psychological Educational Assessment
Social/Emotional-Behavioural Assessment
Psycho-Social Assessment
Vocational Pathways Assessment
Anxiety Programs (Cool Kids or Triple P Fearless Anxiety)

16. Reason for your referral *

17. What do your hope to gain from this service? *

18. If you are seeking an assessment, are you willing to ensure your child has completed a hearing and vision test provided by an optometrist and audiologist respectively prior to assessment being completed (date will be provided to you)?

Yes
No

19. How did you hear about us?

Mindful Directions Psychology Services, Auckland, NZ

Request an Appointment

for Assessments or Anxiety Programs