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    Reason for this referral for assessment. What are your main concerns? What do you hope to find out through this assessment?

    Has your child previously been seen by a psychologist or another specialist such as a Speech Pathologist, Occupational Therapist or Pediatrician, etc.? Please list names of specialists, assessment dates and length of therapy.

    Do you give permission for the assessment report to be shared with other individuals or organisations (e.g. school, Speech Pathologist, etc.)?
    YesNo

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