Assessment Referral | Transdisciplinary Intervention Centre

Upload A Referral Form

If you have your clinic's/center's referral letter or form. File type loadable are jpg, jpeg, png, pdf, and doc.

-OR-

Fill Up the Form Below

Section 1 - Referrer Details
This form is confidential to persons responsible for and those professionally involved with the client. Thank you.
Referrer's Name*
Practice Name*
Position*
Referrer's Email*
Referrer's Contact Noumber*
Section 2 - Client Details
Client's Name*
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Parent’s Name*
Parent’s Contact Number*
Parent’s Email Address*
Section 3 - Reason For Referral
Please state if the client has any existing diagnosis*
- Attention Deficit Hyperactivity Disorder (ADHD) / Attention Deficit Disorder (ADD)
- Autism Spectrum Disorder (ASD)
- Global Developmental Delay
- Learning Difficulties (Dyslexia, Dsygraphia, Dyscalculia)
- Speech & Language Delay
- Sensory Processing Difficulties
- Physical/Fine Motor Difficulties
- Intellectual Disability
- Working Memory
- Anxiety and/or Depression
- Social Communication Disorder
- None of the above
- Other
If you choose other, please specify below. (optional)
This client requires the following:*
- Psycho-educational Assessment
- ADHD Diagnostic
- Giftedness Assessment
- Exam Access Arrangement
- Cognitive Assessment
- Autism Assessment/Diagnosis
- Social Dynamic Assessment
- Occupational Therapy Assessment
- Speech and Language Assessment
- School Readiness Assessment
- Psychological Therapy
- Speech & Language Therapy
- Social Thinking Group
- Other
If you choose other, please specify below. (optional)
Please indicate any other areas of concern that have not been included above.
Section 3 - Other Relevant Information
Please provide any other information that we need to know about this client.
I have discussed this with my client's parents and have been given consent to share this information.*
- Yes

Upload A Referral Form

-OR-

Fill Up the Form Below

Section 1 - Referrer Details

Section 2 - Client Details

Section 3 - Reason For Referral

Section 3 - Other Relevant Information