New Client Intake Questionnaire

Personal information provided on this form will be discussed and shared among agreed members of the Marsden Health (MH) team. This may include Psychologists, Therapy Assistants, Developmental Educators and administration staff. Information will be retained and kept confidential. No information will be shared without further permission from the individual / parent / carer.

To ensure we direct you to the most appropriate service and clinician, it is essential for us to gather detailed information about the individual seeking the assessment. Please respond to all the questions.

Client First Name *

Client Last Name *

Preferred Name (if different from your legal name)

Client Date of Birth *

Client Age *

Address *

Phone / Mobile Number *

Email Address *

If patient is a child, name of contact.

I would prefer a *

Female psychologist Male psychologist Either is suitable

Have you had any other psychological support / counselling (recently or in the past)? *

YesNo

Do you have a GP referral and mental health care plan? *

YesNoI will get one before my first appointment

NDIS (National Disability Insurance Scheme) Information

If you are an NDIS participant wishing to engage with our service, your NDIS plan must state "psychology" or "supports for a multidisciplinary team of allied health professionals".

If you intend to use NDIS funding, all paperwork must be completed PRIOR to your initial appointment. If the paperwork is incomplete, payment via EFTPOS/credit card will be expected on the day of service.

NDIS funding cannot be used for diagnostic assessments.

Please tell us a little about why you are seeking support at this time. What are you hoping to gain from therapy, and are there any specific concerns, challenges, or goals you would like to focus on? *

Please provide details of any legal or personal risk factors we need to be aware of (e.g. patient is in out of home care, court proceedings, court orders, parenting orders, risk of self harm, suicide ideation, insurance or work cover claim,DCJ or police involvement) *

Do we have consent to speak with anyone else regarding bookings (e.g. partner, other parent, grandparent)? If yes, please provide their full names and contact details below. *

If client attends school, please provide details (name of school, year)

Any additional comments that might be helpful for us to know (e.g. sibling attends clinic, past client of our clinic, booked in for future assessment)