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

If you have NDIS funding, do you have approval for Capacity Building / Improved Daily Living? *

YesNoCurrently applying / awaiting approvalNot applicable - I do not have NDIS

Does your NDIS plan include provisions for psychological services? *

YesNoCurrently applying / awaiting approvalNot applicable - I do not have NDIS

A note about NDIS:

To engage with our service, your NDIS plan must state "psychology" specifically, or state "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 provide some information about the reason for referral- We’d love to understand how we can best support you. What are you hoping to gain from therapy, and are there any particular concerns or goals you'd 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, 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 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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