ADHD or Autism Application

Please read this application carefully and respond to all of the required questions (marked with a *)

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Please note:

Our services are fully conducted online. You will need access to a computer or smart phone to full in online questionnaires links and PDFs we send you and also in order to meet online with one of our psychologists.

If you are do not have access to these or have someone who can help you with the forms or accessing the session, then unfortunately, we will not be able to offer you our service.

We provide our service online as it gives us the greatest ability to serve the most people regardless of their location in New Zealand and it allows us to keep our costs low meaning meaning we can offer our services at affordable rates.

What support are you looking for? *

Standard ADHD Assessment (online only) - Cost as per pay scale ($800 - $1,500)
Standard Autism Assessment - Cost as per pay scale ($800 - $1,500)
Standard ADHD and Autism Assessments - Combined (online only) - Cost as per pay scale ($1,000 - $2,000)
Brief ADHD Assessment (online only) - $500
Brief Autism Assessment (online only) - $500
Urgent ADHD Assessment (online only) - $2000
Urgent Autism Assessment (online only) - $2000
Urgent ADHD and Autism Assessments - Combined (online only) - $2500

Please select carefully. Note that there is a difference in the services you will get when you select Standard, Brief or Urgent (as well as a difference in the cost). Please refer to the information on this link for details.

Details for Brief Assessments

You have selected one of our brief assessment options. Please note that there these have a fixed cost as below:

Brief ADHD or Autism Assessment - $500

Note: Please note that we do not offer a service for combined brief ADHD and Autism assessments

If you continue wih this option, once you have fully paid and completed the required questionnaires and surveys we pass your application on to our clinical team.

This brief service is generally for the purposes of self-exploration and validation. You will not meet with our Psychologist but you will complete many of the same questionnaires as the full assessment but will not be given an official diagnosis. You will get a letter summarising the findings, and letting you know if further assessment is needed. Should this be recommended and you wish to upgrade to a full assessment, this amount you paid for your brief assessment will be credited towards the cost of a standard full assessment, so you will not pay anything additional overall.

Details for Urgent Assessments

You have selected one of our urgent assessment options. Please note that these have a fixed cost as below:

Urgent ADHD or Autism - $2000

Urgent ADHD and Autism Combined - $2500

If you continue wih this option, once you have fully paid and completed the required questionnaires and surveys we pass your application on to our clinical team. We will guarantee that within 2 weeks you will

Have your appointment with one of our psychologists

Have a full report created (including any diagnosis if appropriate)

This will only be possible if you complete the payment and questionnaires quickly

This service is ideal for acute situations but if you are unsure then please contact our team using info@acfbfund.org.nz with any questions before you submit this application form.

Are you using this diagnosis to seek government funding?

Do you understand that receiving an autism diagnosis through our service (or any service) does not guarantee access to government-funded support, including but not limited to services provided by NASC (Needs Assessment and Service Coordination) agencies. Access to government funding and services is subject to eligibility criteria and assessment processes managed by the relevant agencies. We encourage you to consult with your local NASC agency or other government bodies for more information on funding options and eligibility requirements

Do you understand and agree that you will be charged an additional $1,000 for this in-person service.

Which of these in-person clinics will you want to attend?

Auckland
Wellington
Christchurch
Other - subject to availability

Name *

Please provide the name of the individual who needs the assessment(s)

Gender *

Male
Female
Non binary
Other

Please let us know the gender of the individual who needs the assessment(s)

Other Gender

Please add your gender here

Parent, Guardian or Support Worker Name

Please provide the name of the parent, guardian or support worker if this is an application being created on behalf of someone else. This can be left blank if you are submitting this application for yourself.

Location *

Northland
Auckland
Waikato
Bay of Plenty
Gisborne
Hawke's Bay
Taranaki
Manawatu-Whanganui
Wellington
Tasman
Nelson
Marlborough
West Coast
Canterbury
Otago
Southland

Ethnicity *

NZ European
Maori
Pasifika
European
Asian
North American
South American
African
Other

Email *

Date of Birth *

Phone Number *

Yearly Income *

If this application is for a child (younger than 18) who is still living at home then please make this the household income.

For adult couples (18 or older) this is your household regular income from any source - salary, wages, WINZ, student allowance etc

For any other single adult (18 or older) this is your regular income from any source - salary, wages, WINZ, student allowance etc

Occupation *

If your only income is WINZ or student benefit, how do you plan to pay this fee? Just put N/A if this is not applicable *

How did you hear about The ACFB Fund? *

Why do you want support? *

Do you have any history of trauma? *

Please let us know more details in brief

Have you had any of these previous mental health diagnoses or suspected diagnoses? Select any that apply

Bipolar disorder or manic episodes
Mood disorder
Neurodevelopmental disorder
Personality disorder
Psychosis
Traumatic brain injury
Other

Do you have any current or past significant medical issues? *

Please let us know more details in brief

Are you currently experiencing thoughts of suicide? *

Let us know where else (if anywhere) that you have tried to access support?

Any other information you’d like us to consider in your application? (referral from a therapist, teacher, work, personal circumstances, etc.)

1 month's worth of bank statements or a letter from your ACFB Fund vetted professional *

Click or drag files to this area to upload. You can upload up to 5 files.

You can do this as up to 5 images if you need. Please make sure it is your most recent statement. We are using this to validate your regular income

File Types accepted: jpg,gif,pdf,heic,png,webp,jpeg

Driver's License/ Passport or other means of identity *

Click or drag files to this area to upload. You can upload up to 2 files.

You can do this as up to 2 images if you need.

File Types accepted: jpg,gif,pdf,heic,png,webp,jpeg

Copy of any referral forms you might have from other health providers

Click or drag files to this area to upload. You can upload up to 3 files.

You can do this as up to 3 images if you need.
File Types accepted: jpg,gif,pdf,heic,png,webp,jpeg

In submitting this application I understand/agree with the following :

* That my information and application will be viewed within the ACFB Fund Clinical Team to determine my eligibility.
* I have provided documentation of ALL income sources and understand that if I am dishonest about my true income, I may not be accepted into the program.
* In submitting this application I understand and agree to all the terms and conditions of this program, including the no-refund policy should I make a payment.
* I understand that this is NOT a medication management service. If the results of any assessment include a recommendation for medication then ACFB will refer to the Nelson Clinic (who will accept any diagnosis provided by ACFB). There will be a cost for any services then provided by the Nelson Clinic - they can advise on what those costs will be.
* I also understand that The ACFB Fund will keep confidential records on the statistics around how my application/funding is used and may reach out for this purpose.
* I confirm that all details submitted in this application are true and accurate, to the best of my knowledge.

If you are unsure about any of these, please email info@acfbfund.org.nz with your questions before submitting this application

Agreement *

I agree to all the statements above.

ADHD or Autism Application

Please note:

Details for Brief Assessments

Details for Urgent Assessments

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