New Patient Intake Questionnaire

First Name *

Last Name *

Date of Birth *

Age *

If patient is a child, name of contact (parent, carer, guardian)

Email Address *

Phone Number *

Home Address *

Do you have NDIS funding? *

YesNoCurrently applying / awaiting approval

A note about NDIS: If you intend to use NDIS funding, please let us know now so we can organise the paperwork PRIOR to your appointment. If we're not notified that an invoice is to be processed through NDIS, payment via EFTPOS/credit card will be expected on the day of service.

Please provide some information about the reason for referral *

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, risk of self harm, suicide ideation, 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 below. *

Do you have NDIS funding? *

YesNoCurrently applying / awaiting approval

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

YesNoI will get one before my first appointment

How did you hear about us? *

GPSocial MediaWord of MouthPaediatricianPsychologist / PsychiatristGoogle / online advertisingSchool Third Party Agency

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

YesNo

If patient 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, booked in for future assessment)

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