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.Format: (000) 000-0000.

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

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

Emergency Contact Name (Optional)

First NameLast Name

Emergency Contact Phone Number: (Optional)

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

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)

Are there any court orders regarding your child, custody arrangements or parenting plans? (Optional)

Has your child ever seen a psychologist before?

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)

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)

Child (16 and under) Enquiry Form