Clone of Allie Mackay Child Intake Form

New Client Child Form

Allie Mackay Psychology
Thank you for taking the time to fill out this form. This form will assist us in ensuring we are the best service for your child and help us allocate them to the most appropriate clinician.

Please note that all information is confidential and will be deleted after 14 days if you do not become a client. Please see our privacy policy at the end of this form.

Please note we are not a mental health crisis centre. If you or your child is in danger please exit this form and call 000. NSW Mental Health Crisis Line - 1800 011 511
Child Name*

First NameLast Name
Child Date of Birth*

DayMonthYear
Date
School
MaleFemaleIntersexOther
Child Email
Child Phone Number
15 years and above Format: (0000 000 000).
Address

Street Address

Street Address Line 2

Suburb Post Code

Post Code
Emergency Contact
Parent / Caregiver Name*

Full NameRelationship to child
Email*
Phone Number*
Format: (0000 000 000).

Todays date*

DayMonthYear
Date
Our reception team will identify which psychologist will be the best fit for you. We will call or email you as soon as possible.

Thank you for your patience!
Should be Empty:

New Client Child Form