The Growth Space Intake Form

The Growth Space Intake Form:

Thank you for choosing The Growth Space. Please complete this online form prior to your initial appointment. There is a Consent Form to review and complete, a general questionnaire, and a short 21-item psychological assessment. It should take approximately 10-15 minutes to complete.

CONSENT FORM

Psychological service:

As part of providing a psychological service to you, the psychologist needs to collect and record personal information that is relevant to your situation. This information is a necessary part of psychological assessment and treatment.

Purpose of collecting and holding information:

Your personal information is gathered as part of your assessment and treatment and is kept securely, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service to you. A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, which can be obtained by contacting the psychologist. The Privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about the management of your personal information.

Consequence of not providing personal information:

If you do not wish for your personal information to be collected as outlined in this form or the Privacy Policy, the psychologist may not be in a position to provide the psychological service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for the psychologist to deal with you or if the psychologist is required or authorised by law to deal with identified individuals. In most cases it will not be possible for you to be anonymous or to use a pseudonym, however, if the psychologist agrees to you being anonymous or using a pseudonym, you must pay consultation fees at the time of the appointment.

Access to client information:

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The psychologist may discuss with you different possible forms of access.

Disclosure of personal information:

All personal information gathered by the psychologist during the provision of the psychological service will remain confidential except when:

1. it is subpoenaed by a court; or

2. failure to disclose the information would in the reasonable belief of the (“Insert name of Psychologist/Practice”) place you or another person at serious risk to life, health or safety; or

3. your prior approval has been obtained to

a) provide a written report to another professional or agency. e.g., a GP or a lawyer; or

b) discuss the material with another person, eg. a parent, employer or health provider; or

c) disclose the information in another way; or

4. you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected; or

5. disclosure is otherwise required or authorised by law.

Your personal information is not disclosed to other recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose.

Cancellation Policy:

If, for some reason you need to cancel or postpone your appointment, please give the psychologist at least 24 hours notice, otherwise, you may be charged the cost for the session.

APS Charter for Clients of Psychologists
The Charter explains your rights as a client of a psychologist and can be found here:

https://www.psychology.org.au/for-the-public/about-psychology/why-choose-an-aps-psychologist/Charter-for-Clients-of-APS-Psychologists

I, (type name below), have read and understood this Consent Form. I agree to the above conditions for the psychological service provided by Greg Cameron.

Type full name here

Signature

Please note: If, after reading this form you are at all unclear about any of the information provided, please enter "I do not consent" in the above "Type full name here" box and the psychologist will discuss with you prior to your initial appointment.

GENERAL QUESTIONNAIRE

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email*

Who referred you?

Do you have a Mental Health Care Plan from you GP?

Yes (please email through to info@thegrowspace.com)No

Relationship History: (List, in chronological order, all marriages or cohabitation relationships)

	Name of Spouse/Partner	Length of relationship	Date of Separation	How it Terminated
1
2
3

Medical History: (List all prescription medications you currently take)

	Medication	Dose	Reason for Taking
1
2
3

Please describe your typical use pattern for the following substances:

Do you have a criminal history in the last 10 years, or violent offences ever?

YesNo

Employment History: (List all jobs held in the last five years)

	Name of Employer	Position	Year	Reason for Leaving
1
2
3

Education History:

	School Name, Degree/Diploma	City/State	Year Completed	Last Grade Completed
1
2
3

Children (if applicable):

	Name	Age	Living with
1
2
3

Is there any other relevant information you would like to provide prior to the initial appointment?

0/100

DASS 21

Please read each statement below and respond to the 21 items with either number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:
0 Did not apply to me at all - NEVER
1 Applied to me to some degree, or some of the time - SOMETIMES
2 Applied to me to a considerable degree, or a good part of time - OFTEN
3 Applied to me very much, or most of the time - ALMOST ALWAYS

1. I found myself getting upset by quite trivial things*

	0	1	2	3