ACFB Psychological Assessment Application Form

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

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Applicant's Name *

First

Last

Applicant's Email *

Confirm Email

Applicant's Phone Number

Applicant's Date of Birth *

Gender *

Male
Female
Non-Binary
Other

If other, and wish to explain:

You can advise how you would like your gender to be defined here

Location *

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

Ethnicity *

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

How did you hear about The ACFB Fund? *

Parent, Guardian, or Support Worker's Name

First

Last

*If applicable - This is not required for clients 18 years+ but can be supplied for anyone

Parent, Guardian, or Support Worker's Email

Confirm Email

Parent, Guardian, or Support Worker's Phone Number

Which pathway best suits you? *

Sliding scale - will require income testing
WINZ - will require a WINZ verfication letter dated within 30 days of application
Student ID - tertiary students with a valid ID
Standard - no income testing

1 month's worth of bank statements, a WINZ letter or an IRD Summary of Earnings *

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

Please provide a copy of your identification. *

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

Please make sure this shows an your image, name and date of birth. You can do this as up to 2 images if you need.

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

Are you currently in crisis or experiencing thoughts of suicide with the intent to harm yourself? *

Have you ever experienced the following (Select all that apply) *

None apply
ADHD
Autism
Bipolar disorder or manic episodes
Depression - short term
Depression - long term
Chronic medical problems
OCD
Domestic violence
Seizures
Iron deficiency (current)
Anxiety - short term
Anxiety - long term
Self harm
Attempted suicide
Homelessness
Neurodevelopmental disorder
Personality disorder
Psychosis
Traumatic brain injury or other head injuries
Addictions
Medical trauma

We ask these questions to better determine your need for a full assessment. Please answer these questions honestly as they affect the selections below.

We reserve the right to upgrade your application at any time should we feel your needs are better suited by our Full Assessment (ADHD, Autism, and Mental Health).

From the answers you provided above, there are your options. Please select one. *

Mental Health
Full assessment (ADHD, Autism, and Mental Health)

Which assessment are you applying for? *

Autism
ADHD
Mental Health
Full assessment (ADHD, Autism, and Mental Health)

Are you looking for medication for ADHD and/or any other psychiatric concern with this assessment? *

Are you seeking this assessment for the purposes of applying with a NASC provider for any funded services (autism only - examples: respite, individualised funding, etc) *

Based on your answers above, please choose the Diagnostic Pre-screening (Step 2) option you prefer: *

Brief Pre-Screening
Standard Pre-Screening
Enhanced Pre-Screening

Please note: if you select a Brief Prescreening, you will not be able to progress to any further steps. This is not a diagnosis, this is merely a screen and report of findings. To get an official diagnosis, please choose Standard or Enhanced Pre-Screening.

Based on your answers above, please choose the Diagnostic Pre-screening (Step 2) option you prefer: *

Standard Pre-Screening
Enhanced Pre-Screening

to additional (Step

Based on your answers above, this is the Diagnostic Pre-screening (Step 2) option available: *

Enhanced Pre-Screening

Based on your answers above, please choose the Diagnostic Interview (Step 3) option you prefer: *

Standard Online Interview
Urgent Online Interview

Based on your answers above, this is Diagnostic Interview (Step 3) option available: *

In-Person Interview

Which In-Person clinic location are you interested in? *

Auckland
Hamilton
Wanganui
Palmerston North
Wellington
Christchurch
West Coast
Dunedin

Based on your answers above, please choose the Diagnostic Reporting (Step 4) option you prefer: *

Standard Reporting
Urgent Standard Reporting
Enhanced Reporting
Urgent Enhanced Reporting

Based on your answers above, please choose the Diagnostic Reporting (Step 4) option you prefer: *

Enhanced Reporting
Urgent Enhanced Reporting

Are you interested in adding any of these additional Psychological Services on to this application. Doing so will save you money as opposed to ordering this service at a later time. *

No, thank you!
Treatment Planning (TP)
Functional Assessment (FA)
Combination - TP & FA
Workplace Accommodations Report (WAR)
Educational Accomodations Report (EAR)
Full Service - TP, FA, & WAR
Full Service - TP, FA, & EAR

Are you interested in adding any of these additional Clinical Services? We can get these going while you wait for your assessment results. *

No, thank you!
Whanau Support
Occupational Therapy
Counselling

ACFB Psychological Assessment Application Form

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