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Referral for Educational Assessment
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* Indicates required question
Email
*
Your answer
Date of referral
MM
/
DD
/
YYYY
My name
*
Your answer
My relationship to student/person being assessed
Your answer
I have legal authority to refer this person for assessment
Yes
No
Unsure
Other:
Clear selection
Name of Student/Person to be assessed
*
Your answer
Age of person being assessed
Your answer
Date of Birth of Student
MM
/
DD
/
YYYY
What are you most concerned about for this learner?
Your answer
What do you hope that an assessment will achieve?
Your answer
Is the learner attending school?
Yes
No
Other:
Clear selection
Name of school or learning centre
Your answer
Is the learner's first language English?
Yes
No
Clear selection
There is a one-off charge of $855 for assessments, required before the report is released. (Discuss funding possibilities with your school if needed.)
Yes. That's fine.
Are there any other background, health, or behavioural issues that may be important for the assessment? i.e. ADHD, hearing or vision problems, etc.
Your answer
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