Your Counselling Ltd.

Assessment Request

Tell us about the assessment you are interested in. Our intake team will review your request and contact you.

Tell us about you, or the person you are requesting an assessment for, and what you are hoping to learn. It takes about 5 minutes.

Our intake team reviews every request with your psychologist and gets in touch to recommend the right assessment, confirm the fee and book your first appointment. Sending this form does not book an appointment or commit you to anything.

If you have any issues or questions about this form please contact our office.

About you

Your Name
Best way to reach you
Best times to reach you

Who the assessment is for

Who is the assessment for?
Date of Birth of the person being assessed

The assessment

Which assessment are you interested in?
A few sentences is plenty. You can share more at your intake appointment.
What will the report help with? Check all that apply.
Has there been a previous psychological or psychoeducational assessment?

Practical details

How are you planning to pay? Check all that apply.
Has anyone referred you?

This form is not monitored for urgent concerns. If you or someone else is in immediate danger, call 911. For mental health crisis support, call or text 988.

Consent