A welcoming idylic forest imageAppointments

To arrange for an appointment with Judy, please complete the following form.

A PDF version may be viewed here. You may print it out and bring the completed copy with you to your appointment

Personal Details
 e.g. DD/MM/YYYY
 List names of both parents (if applicable) and their occupations
 Addresses of both parents, if different
Phone Numbers:
 e.g. (xx) xxx xxxx
 e.g. xxx xxx xxxx
 Please supply 3 reasons
 what has been tried before, e.g. extra tuition, homework, RTLB, home support
 Please include names and ages of siblings as well as any other relevant information
 Please include relevant information (pregnancy, speech and language, social skills)
 Have recent assessments been conducted? If so, please include dates and results. Any history of vision or hearing difficulties, recurrent ear infections, etc.
 Please include relevant details including any previous and current prescribed medication/s, surgery
 Please include any interests (e.g. sports), activities/games, favourite subjects etc
 These may include academic, social or behavioural difficulties. Please provide details.
Web Form Code
Enter Code As Shown:

Additional information can be brought to the first appointment.

Disclosure Statement

Northside Psychology & Education Associates
Judy Selvaraj
MEd (First Hons)
MA (Hons); BA; Dip Tchg
Doctoral Candidate
(The University of Auckland)

North Shore City
New Zealand

Tel: Please Enquire