Psychology Intake Form
Who is seeking counseling?
Myself
My Child
Other
Personal Information of Counseling Person
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
School Name (If Applicable)
School Year (If Applicable)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Your Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is your address same with the counseling person?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship with the counseling person
Parent
Grandparent
Carer
Friend
Other
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Referral Information
How did you hear about us?
General Practitioner
Specialist
Family or friend
Social Media
Internet Search
Other
Referrer Name
First Name
Last Name
Referral Date
-
Month
-
Day
Year
Date
Funding Information
Mental Health Treatment Plan
Private Health Insurance
NDIS
Work Cover
Self-funded
Other
Counseling
Reason for Counseling
Abuse
Addiction
Adjustment
Ageing Concerns
Anger
Anxiety
Depression
Displacement
Eating Disorders
Family
Financial Problems
Grief & Loss
Identity
Learning Difficulties
Loneliness
Obsessive Compulsive
Panic Attacks
Parenting
Post-Traumatic Stress
Relationship
Self-Esteem
Self-Harm
Sexual Issues
Sleeping
Smoking
Stress
Suicidal Thoughts
Trauma
Weight Concerns
Work Stress
Other
Please specify any previous counseling experiences
e.g. Mental Health Treatment Plan [MHTP], Employee Assistance Program [EAP], Private
Please specify any medical/allied health services who have been/are involved
Permission is given for the psychologist to obtain and exchange appropriate written or verbal information with the following persons/agencies
Please specify any diagnoses
Please specify all medications
Please specify any other concerns
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: