CP_AssessRequestForm | ARKCC Therapy Centre

Psychological Assessment Proposal

Purpose of this form
To be completed by the clinician after the intake session when a psychological assessment is being proposed.

This form supports clinical justification, scope clarity, time and cost estimation, and centre review for appropriateness and governance.

Client Name

Date of Intake Session: required

Summarise key presenting concerns, symptom patterns, and relevant background identified during intake. Avoid full case notes.

Primary concerns observed/reported:

Duration & pervasiveness of symptoms:

Functional impact (work, study, relationships, daily living):

Relevant psychosocial / medical history (if any):

SECTION 3: Purpose of Assessment (Outcome‑Focused)

Why is the assessment being conducted? What is it intended to support or clarify?

Outcome-Focused Required

Brief description of intended outcome:

SECTION 4: Rationale for Proceeding With Full Assessment (Clinical Justification)

Why is intake alone insufficient? Why is a comprehensive assessment clinically appropriate?

Clinical Justification Required

Intake findings are inconclusive

Symptoms overlap across multiple domains

Differential diagnosis required

Objective measures needed to support diagnosis

Functional impairment requires formal documentation

Client requests full assessment after explanation of alternatives

Other

Clinical rationale summary:

SECTION 6: Proposed Assessment Scope, Level, Tools & Methods

Why is intake alone insufficient? Why is a comprehensive assessment clinically appropriate?

Overall Level (select one) Required

Screening‑level assessment

Focused assessment (single domain)

Comprehensive psychological assessment (multi‑domain)

Domains to be assessed (tick all that apply): Required

List all tools proposed. Clinician‑owned / licensed tools to be declared. Centre does not mark up test costs.

Additional methods (if any): Required

Clinical interview(s)

Collateral interview (family / partner / employer)

Behavioural observation

Self‑report questionnaires

Declaration on Test Materials & Licensing

I confirm that all licensed tools listed are legally obtained and used in accordance with professional and publisher guidelines.

SECTION 7: Estimated Time Commitment

Estimate total professional time required. This supports pricing justification.

Activities

Estimated Time

(Hours)

1. Assessment session(s) with client

2. Test administration

3. Scoring & interpretation

4. Report writing

5. Feedback / results session

6. Professional review / integration

7. Others

Number of assessment sessions required:

Estimated duration per assessment session:

Estimated completion timeline (from consent):

Expected Clinician's charge for this proposal (includes all Test Material Cost)"

Brief description of assessment steps, sessions and duration, what the client will receive (e.g. report, feedback):

SECTION 7: Estimated Time Commitment

Estimate total professional time required. This supports pricing justification.

Activities

Clinician Declaration

I confirm that the proposed assessment is clinically appropriate, proportionate, and ethically justified based on intake findings.

Clinician Name & Registration No.

Clinician Signature

Psychological Assessment Proposal

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