Child (16 and Under) Enquiry Form

Child (16 and under) Enquiry Form
Childs Name*

First NameLast Name
Parent One Name: (Name of parent enquiring)*

First NameLast Name
Parent Two Name: (Optional)

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Preferred day for an appointment (please note that we can not guarantee that we can offer this time, this is not a booking) :*

MondayTuesdayWednesdayThursdayFirst Available
Preferred time for an appointment (please note that we can not guarantee that we can offer this time, this is not a booking) :*

9 am - 11 am12 pm - 2 pm3 pm - 5 pmFirst Available
Emergency Contact Name (Optional)

First NameLast Name
Emergency Contact Phone Number: (Optional)
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Grade in School: *
Referral Type: *
GP/ Referring practitioners name: (Optional)
Please type N/A if you do not have one yet.
Please briefly describe your current concerns and/or circumstances: (Please let us know how we can help) *
Are you concerned that your child is at risk of harm (self other otherwise) or suicide?*
Family circumstances: (Who does the child reside with? Please tick all that are relevant to your child)*

Two ParentsSingle Parent FamilyShared Care Between ParentsOnly ChildSibling/SiblingsExtended Family (Grandparents, Aunties, Uncles Etc)
Are there any court orders regarding your child, custody arrangements or parenting plans? (Optional)
Has your child ever seen a psychologist before?*

YesNoPrefer not to say
Psychologists name: (Optional)
Suggested Diagnosis: (Optional)
Our clinical team will call you shortly, please select the days which are the most convenient for you: (please choose all relevant options)*

MondayTuesdayWednesdayThursdayFriday
Please call me during this time:*
If you or your child are in crisis and feel that you need immediate assistance please call:

Lifeline on 13 11 14 for 24/7 mental health and crisis support,

NSW Mental Health Line 1800 011 511 for advice and referrals

In the case of emergencies or suicidality please call 000 or present to your local hospitals emergency department.
Where did you hear about us? (Optional)

Word of MouthWeb searchGeneral PractitionerSocial MediaSpeech PathologyFriend of Family MemberOther
Should be Empty:

Child (16 and under) Enquiry Form