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About DSKC
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Locations
Mill Park Clinic
South Morang Clinic
Mobile Service
View all Locations
Referrals
Services
Autism Spectrum Assessment
Group Therapy
Occupational Therapy
Psychology
Speech Pathology
Mobile Service
NDIS
Careers
View Open Roles
Graduate Program
Senior Therapist Program
Hub
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Psychology Intake form
Psychology
Inclusion Criteria
Exclusion Criteria
Paediatric Clients, aged 2-18 years of age
Clients experiencing difficulties in areas such as mental health, learning, development and/or behaviour. Some areas a psychologist can help are:
Cognitive assessment
Autism Spectrum Disorder Assessments
Social communication
Behaviour support plans
Anxiety & Depression
Emotional regulation
Stress management
Parenting skills
Counselling
Kindergarten and school support
Eating disorders – please refer to specialist psychologis
Family court
Acute mental health e.g. psychosis/suicide
Our psychologists do not work with the presentations in the exclusion criteria above. Please tick the box below to confirm your understanding of the exclusion criteria:
(Required)
Please see here for specialisations
Yes – I have read and understood the exclusion and inclusion criteria
Your Full name
(Required)
Please select the most appropriate option to describe yourself
(Required)
Please select
Support Coordinator
Parent/Guardian of the child
Allied Health Professional
Other
Client’s Details
Child's Full Name
(Required)
First
Last
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Date of Birth
(Required)
DD slash MM slash YYYY
Gender Identity
(Required)
Cultural Identity
Preferred Language
Interpreter Required?
Educational Setting
(School, Childcare, Kinder)
Health Conditions
(Diagnoses, Medications)
Preferred Contact Person Detail
Contact Name
Relationship Type
Email Address
Phone Number
Funding Details
Funding Type
NDIS
Medicare
Private
NDIS Number
Plan Start Date
DD slash MM slash YYYY
Plan End Date
DD slash MM slash YYYY
How are the NDIS Funds managed?
Self-managed:
The Participant has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, the Provider will send the Participant an invoice for those supports for the Participant to pay. The Participant will pay the invoice by EFT within 7 days
Managed by Plan Nominee:
The Participant’s Nominee manages the funding for supports provided under this Service Agreement After providing those supports, the Provider will send the Participant’s Nominee an invoice for those supports for the Participant’s Nominee to pay. The Participant’s Nominee will pay the invoice by EFT within 7 days.
Managed by NDIS:
The Participant has nominated the NDIA to manage the funding for supports provided under this Service Agreement. After providing those supports the Provider will claim payment for those supports from the NDIA.
Managed by a Registered Plan Management Provider:
The Participant has nominated the Plan Management Provider to manage funding for NDIS supports provided under this Service Agreement. After providing those support, the provider will claim payment for those supports from:
Plan Manager Name
(if applicable)
Please upload your child's NDIS Plan or a screenshot of goals and allocated funding
Drop files here or
Select files
Max. file size: 256 MB.
Are there any family court orders in place?
Yes
No
Please attach court order document
Drop files here or
Select files
Max. file size: 256 MB.
Child lives with:
Both parents in one home
Both parents in 2 separate homes. If so, what is the percentage split?
Other
What is the percentage split?
Provision: Services Sought (Pick one, both or skip if unsure)
Assessment
(Assessing what is currently occurring for the client regarding the areas of concern)
Intervention
(Implementing strategies with the client to address areas of concern)
Type of Assessment
(if known)
Type of Report
(if required)
Preferred Session Frequency
Monthly
Fortnightly
Weekly
Other
Format of sessions
Face to face (in clinic)
Outreach (home, educational setting)
Virtual
Please also include in the assessment/intervention:
Preferred day/s of the week:
Preferred time slot/s:
Reason for Referral/Summary of Concerns?
Mental health
Behaviour
Autism Spectrum Disorder
ADHD
Social skills
Anxiety
Advocating for self
Family therapy
Other?
Other?
(Please provide as much detail as possible)
Additional Services that may be required:
Occupational Therapy
OTs support with meaningful engagement in everyday occupations including: play, mealtimes, dressing, and other activities that are important to your child
Speech Pathology
Speech pathologists assist in communication, play, social skills, literacy and conversation skills etc.
Referrer Details
Referral Source
Internal (from DSKC)
External
Referral Date
DD slash MM slash YYYY
Full Name
(Required)
Agency/Organisation
Email
Contact Number
How did you hear about De Silva Kids Clinic?
Word of Mouth
Google
Social Media
Our website
GP
Other Allied Health Practitione
Support Co-ordinator
Other
NDIS Service Agreement Notice
You have selected NDIS funding. You will now be redirected to the NDIS Service Agreement for your review and authorisation.
We’re sorry 😢
We’re sorry, but we’re unable to process your form submission as it appears you are not a parent and/or have not confirmed that you have read and understood the inclusion and exclusion criteria.
Please review the criteria carefully and try again. Thank you!
