Assessment Enquiry Form

Client Information

What is the client's name?

What is your relationship to the client?

What is the client's DOB?

Is the client over the age of 18? *

Permission Required: If the client is over 18, you will need permission to be making an enquiry on their behalf.

Do you have the client's permission to proceed with this enquiry? *

About the Client

Do you identify as any of the following?
AboriginalTorres Strait IslanderAboriginal and Torres Strait Islander

Please provide as much detail as possible about your reason for seeking an assessment.* This might include:
- Who recommended the assessment (e.g., school, GP, psychologist, employer, self-referral)
- The specific concerns you or others have noticed (e.g., difficulties with learning, behaviour, attention, emotional regulation, or social interaction)
- The type of assessment you believe may be needed (e.g., cognitive, educational, autism, ADHD, mental health, developmental)

This information helps our team understand your needs better and ensures we can provide the most suitable path forward.

Scheduling Preferences

Preferred Appointment Days: *
MondayTuesdayWednesdayThursdayFridaySaturdayAny Day

Preferred Appointment Times: *
Before WorkAfter WorkMorningLunchtimeAfternoonEveningAny Time

Additional Services

Lilley Place is a multidisciplinary clinic with over 20 allied health professionals offering a wide array of services. Additional services can be accessed prior, during, and after presenting for an assessment.

Which other service/s are you enquiring about?
Psychology
Accredited Mental Health Social Worker
Somatic Movement and Trauma Sensitive Yoga Therapy
Dietetics
EMDR
Exercise/Mental Health Physiotherapy
Other

Provider Preferences

Is there a specific provider you would like to make appointments with at Lilley Place? *