Intake form Educational assessments - Tertiary institutes

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Medical aid details

Principal member Name *

First

Last

Medical aid: *

Membership number: *

Dependent code *

Details of client

Name *

First

Last

Date of birth *

Cell number *

Home Language *

History of current academic problem *

At what age was the problem first noted?

Have you been assessed previously by an educational psychologist? If yes, please specify when and what (if any diagnoses were made). *

Attach previous assessment(s) (This is optional but strongly encouraged)

Click or drag files to this area to upload. You can upload up to 4 files.

Please attach latest results report (or more if available)

Click or drag files to this area to upload. You can upload up to 4 files.

School history

Please indicate where you attended Grade R and primary school and during which years. *

Please indicate where you attended high school and during which years. *

Current scholastic functioning

How would you rate your performance, according to ability? *

Below
Above
As expected

How do you feel about your academic progress? *

Satisfied
Worried
indifferent

Does your performance vary from day to day? *

Has there ever been a sudden change in performance? *

Have you ever repeated a school/university year? If yes please indicate when *

What is your general attitude towards university? *

Enthusiastic
Indifferent
Would prefer not to go

Please indicate any extra-mural activities (in or out of university): *

Please provide the name and email address of a family member whom you feel knows you best in the home environment *

Did your educators identify any learning related issues during primary or high school?

Please indicate any problems related to sensory development: Vision

Please indicate any problems related to sensory development: Hearing

Specify any traumatic injuries and/or operations along with age at particular time:

Have you ever experienced any of the following? *

Convulsions
Fits
Black-outs
Cerebral concussion
Habit of banging head
N/A

Medical history

Please provide information on any medication you are taking at present: *

Dose

Period used

reason for prescription

Does any other member of your family suffer from a serious chronic illness? If so please decribe:

Please specify if any member of your family is neurodiverse (e.g ADHD/Autism Spectrum) or suffers from any psychiatric conditions (E.g. depression/anxiety/eating disorders)

Just a reminder that is strictly confidential.

Briefly describe any past or present emotional difficulties (e.g. frequent nightmares, detached affect): *

Briefly describe any past or present behavioural difficulties (e.g. frequent nightmares, detached affect): *

Please elaborate on social concerns (if any)

Are you currently seeing an academic tutor? (If yes please state for which subject)

How would you rate your short term memory? *

Superior
Above average
Average
Below average

How would you describe your ability to sustain attention and concentration? *

Please detail any particular current learning difficulties:

Is their any history of family struggling with learning difficulties at school? *

Consent form

1. Acknowledge that the information collected by means of psychological tests is only meaningful if it is interpreted by somebody who knows the theory which underlies the relevant test and interprets it in the context of the situation.

2. Acknowledge that the limitations of the specific tests will be explained to me when required.

3. Am aware that the raw scores which are obtained from the tests used during the assessment will only be released to education institutions for concession applications when required.

4. Give consent to communicate information and reports (where applicable) via email and/or Whatsapp messaging platform.

5. Acknowledge that I/we gave my/our consent, willingly and without being unduly influenced to do so by my/our therapist or any other person.

Please note that all private information collected about you will be treated as highly confidential; no information will be disclosed without your consent, unless we feel you are at harm to yourself, others or if required to do so by a court of Law.

Feedback session preference

online (google meet)
in-person
report only no feedback

Please note that should you choose not to have a feedback then this session will not be billed for.

Payment instructions

Please note that Dayne Williams operates as a cash practice and therefore the patient is responsible for payment. Once payment has been made you will be issued with a receipt which can be used to claim back from medical aid. Please consult your medical aid first to ensure funds are available for psychological sessions.

Payment must be made on or before the day of assessment with a POP sent to accounts@daynewilliams.co.za. Please consult https://daynewilliams.co.za/fees for assessment cost. No assessments can commence without this. Please find banking details below

Bank Details

Account Holder: D Williams and Associates

Bank Name: FNB

Branch Number: 050655

Account Number: 63117157156

Please use name and surname as a reference

Signature *

Date *