Intake Form PSYCHOLOGY / COUNSELLING INTAKE FORM Please enable JavaScript in your browser to complete this form.Are you: *Under 18Over 18Attending as a coupleName *FirstLastTitleTitleMr.Mrs.Ms.Date of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of BirthRelationship status *Relationship statusSingleIn a relationshipMarriedSeparatedDivorcedWidowedDe-FactoEmail *Phone *Address *Suburb *Post code *State *StateQueenslandNew South WalesVictoriaWestern AustraliaSouth AustraliaTasmaniaPlease be aware that if there is a custody arrangement in place both parents consent is required for the sessions to go ahead. If the second parent's consent is unable to be obtained please call us to discuss options.Parent/ Guardian 1 *FirstLastTitleTitleMr.Mrs.Ms.Address *Email *Phone *Parent/ Guardian 2FirstLastTitleTitleMr.Mrs.Ms.AddressEmailPhoneParty 1 *FirstLastTitleTitleMr.Mrs.Ms.Date of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of BirthAddress *Suburb - Party 1 *Post code - Party 1 *State - Party 1 *StateQueenslandNew South WalesVictoriaWestern AustraliaSouth AustraliaTasmaniaEmail *Phone *Party 2 *FirstLastTitleTitleMr.Mrs.Ms.Date of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of BirthAddress *Same addressOther. Please specifyAddress Party 2 *Suburb - Party 1 (copy) *Post code - Party 1 (copy) *State - Party 1 (copy) *StateQueenslandNew South WalesVictoriaWestern AustraliaSouth AustraliaTasmaniaEmail *Phone *Emergency Contact Name *FirstLastEmergency Contact Phone *Name of referring GPName of clinic referral was obtained fromReason for CounsellingAbuseAddictionADHDAngerAnxietyAutismBullyingDepressionEating DisordersFamilyFeeling NervousGrief & LossLearning ConcernsObsessive CompulsivePanic AttacksParenting IssuesPost Traumatic StressRelationship IssuesSelf-Harm/Suicidal ThoughtsSleeping ConcernsStressTraumaWeight IssuesOtherThis information will help your Therapist/Counsellor to understand your needs.Do you have a court order in place? *YesNoHave you had any previous counselling this year? *YesNoDo you hold NDIS plan? *YesNoPlan number: *Plan Start Date: *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Plan End Date: *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How is your Plan Managed: *Self ManagedPlan ManagedPlease specify details of Plan Manager including contact details *Do you give consent for SMS appointment reminders? *YesNoHow did you hear about us?GPGoogle searchSocial mediaReferred by someoneOther. Please specifyOtherConsent form Purpose of holding information: As part of providing a counselling service to you, your psychologist/counsellor will need to collect and record personal information from you that is relevant to your current situation. It’s important to collect this information as it forms a necessary part of assessment and treatment that is conducted. Confidentiality: All personal information gathered by the psychologist/counsellor during the provisions of counselling services will remain confidential and secure expect when: It is subpoenaed by a court; Failure to disclose the information would place you or another person at risk; Your prior approval has been obtained to: Provide a written report to another professional or agency (e.g. a lawyer); Discuss the material with another person (e.g. a parent) If you are referred by a GP under a MHTP, you are consenting to the exchange of written/ verbal correspondence regarding your treatment and progress. consent *I have read and understand the above consent formChanging or canceling appointments: We understand that at times you may need to cancel or reschedule your appointment. As our service is in high demand, we would appreciate it if you could provide 24 hours’ notice. Failure to provide adequate notice will incur a fee of $70.Submit
