Intake Form
Please complete the information below to tell us about your child and the reason for referral.
Family Information
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Day
-
Month
Year
Date
Child's Gender
*
Male
Female
Other
Child's Address
*
Street Address
Suburb
State
Post Code
Is the child in Out of Home Care?
Yes
No
Parent/Legal Guardian 1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: 0000 000 000.
Email
*
example@example.com
Parent/Legal Guardian 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: 0000 000 000.
Email
example@example.com
Parent/Guardian Relationship:
*
Married
Defacto
Separated
Are there current court orders in place?
*
Yes
No
Child lives with:
*
Please Select
Parent Guardian 1
Parent Guardian 2
Both
Other
Funds
Funding for Services (choose one)
Medicare
NDIS
Private Health Fund
Child's Medicare Number
*
Child Medicare Reference #
*
Child Medicare Expiry Date
*
-
Day
-
Month
Year
Date
Parent's Medicare Number
*
Parent Medicare Reference #
*
Parent Medicare Expiry Date
*
-
Day
-
Month
Year
Date
NDIS Funding
*
Self-Managed
Plan Managed
NDIS Plan Manager
*
Enter name of Plan Manager (if applicable)
Private Health Fund Provider (if applicable)
Enter name of Health Fund
Reason for Referral
Please tick one or more of the following reasons for seeking psychological services for your child:
*
Anger issues
Anxiety
Autism
Behavioural issues
Depression
Eating disorders
Grief & loss
Inattention/impulsivity
Learning difficulties
Obsessive/compulsive
Panic attacks
Phobia
School refusal
Self-esteem
Self-harm
Sleeping issues
Social skills
Suicidal thoughts
Toileting issues
Trauma
How did you hear about us?
*
General Practitioner
Specialist
Family/Friend
Social Media
Internet Search
Other
Submit
Should be Empty: