New Client Enquiry Form

New Client Enquiry Form

With a focus on children and adolescents, we aim to deliver high quality psychological services and hope that your experience with us is exceptional.
Completing the form below allows us to get things started for you and your family. The information you provide will help us to determine which of our psychologists is best suited to assist your child and provide us with some understanding of what you have been up against.

Please be assured, any details you note below stay confidential and will only be accessed and used to contact you regarding appointment options. Once you have completed the below information, you will be placed on our waitlist and contacted as soon as a suitable appointment becomes available.

If you have any concerns at all providing any of this information, please call one of our friendly staff on 02 9564 3758.
Child's Full Name*

First NameLast Name
Child's Date of Birth*

DayMonthYear
Date
Suburb of Residence
School
Parent/Caregiver's Full Name*

First NameLast Name
Phone Number*
E-mail*
Other Parent/Caregiver's Full Name*

First NameLast Name
Relationship Between Caregivers*

MarriedDefactoSeparatedDivorcedWidowedSingle ParentElective Co-parenting
Will both parent consent to treatment?*

YesNoN/A
How did you hear about us?*

GPPaediatricianPsychiatristFamily/FriendSchoolInternet
Name of referrer
Do you have a friend or family member who has been to Sydney Children's Practice?

YesNo
Please tell us a little about the main concern for your child*
Has your child had previous psychological treatment?*

YesNo
If Yes, please describe below
Funding Type

Medicare (have received an MHCP)NDIS (self managed only)PrivateUnsure
Preference for a specific clinician?
After school appointments are popular and can be difficult to book, is your child able to attend ongoing sessions during the school day?*

Yes - we are willing to attend appointments within school hours (9:30am - 1:30pm)No - requires after school appointments only (7:30am-9:30am and 2:30pm-7:00pm)
I give permission for Sydney Children's Practice to contact me on a monthly basis via SMS and email to provide updates regarding the waitlist and appointments*

YesNo
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