Appointment Request Form - Learning difficulties

Learning Difficulties Appointment Contact Form

Please fill out the Appointment Request Form

Learning Difficulties (e.g., reading, written expression, spelling, maths)

Parent/Carer First & Family Name (required)*

Child’s/Teen’s First & Family Name (required)*

Child’s/Teen’s Date of Birth (used to set up the assessment)*

Child’s/Teen’s School Year Level*

Has your child repeated a year level? If so, which year level and year of repeating (e.g. Repeated Year 3 in 2021) (required)*

Areas of Concern (e.g. struggles with reading & spelling) (required)*

Any specific support at school, such as small-group learning support or placement in the school’s MultiLit program, etc.

Do you suspect (or has there been a diagnosis for) any co-existing condition(s) impacting education, e.g., ADHD

Your reason for seeking this assessment.

Your Email (required)*

Your Phone Number*

How did you hear about Purple Giraffe Psychology?

Search Engine

School Referral

Friend Referral

Other

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Thank you for providing this information to help Purple Giraffe Psychology better understand your child’s needs. Purple Giraffe Psychology will be in touch with you soon.

Information collected will remain confidential and will not be used for marketing purposes.

Not sure?

Contact Lyn direct on 0412 922 446

Learning Difficulties Appointment Contact Form

Not sure?

Parent Information

Teacher Information

Purple Giraffe Psychology

Purple Giraffe Psychology - Holdfast House, Suite 8/1-5 Sussex Street, Glenelg, Adelaide SA