New Patient Intake Questionnaire

PLEASE READ BEFORE COMPLETING THIS FORM:

Please note that our waitlists for children aged 2-11 years and NDIS patients for all age groups are currently CLOSED.

If your enquiry is about becoming a new therapy client as above, we kindly ask that you do not submit this form, as we are not able to accept new therapy bookings at this time.

We understand how important it is to find the right support, and we truly appreciate you considering us. Availability can change, so we encourage you to check back with us in the future.

If your enquiry is about an assessment, please complete our assessment intake questionnaire via our email and we will be in touch to discuss next steps
If your enquiry is regarding NDIS education and support (parent-focused, including help with applications and review preparation), please complete the form below and we will be in touch to discuss next steps

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 *

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. *

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)