Appointment Request
OCD Clinic Brisbane
Welcome
Well done in taking the first step in reaching out. This form helps us understand your needs and match you with the most suitable clinician. Your information is kept confidential and securely stored. This is an appointment request—our team will contact you with next steps. Please do not use this form in an emergency. If you are in crisis or at immediate risk, please contact emergency services, GP, Lifeline 131 114 or 000.
Personal Details
If you are completing this form on behalf of your child, please complete the below with their details
Name of Parent/Caregiver (if applicable)
Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Date Picker Icon
Age
*
What are your preferred pronouns?
*
She/Her
He/Him
They/Them
Prefer not to say
Other
Who is this appointment for?
*
Adult
Adolescent
Child
Cultural Background / Ethnicity. (Choose all that apply.)
*
Email
*
example@example.com
Contact Number
*
Enter your mobile or best contact phone number
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Best contact method
*
Phone
Email
SMS
Appointment preference
*
In person
Telehealth
Either
Preferred days/times
*
Monday
Tuesday
Wednesday
Thursday
Friday
Flexible
When do appointments generally suit you best?
*
Morning
Afternoon
Either is fine
Are you seeking an assessment?
*
ADHD Assessment
Autism Assessment
Cognitive Assessment
Diagnostic Clarification or Second Opinion
Cosmetic Preparedness Assessment (Surgery)
Not Applicable
Presenting Concerns?
*
Obsessions and Compulsions
Excessive Worry
Panic Attacks
Social Anxiety
Heath Anxiety
Phobias
Depressed Mood
Life and Work Stress
Sleep Difficulties
Autism
ADHD or Executive Functioning Issues
Gender or Identity Related Issues
Body Image or Negative Relationship with Food
Skin Picking
Hair Pulling
Hoarding Disorder
Body Dysmorphia
Other
What are the primary presentation/s or symptom/s you are seeking support for?
*
Do you have any diagnoses?
*
Is there anything else you would like us to know? (optional)
Do you have a preference for a male or female psychologist?
*
Female Only
Male Only
No Preference
If there's a specific psychologist you'd prefer to see, please list below:
Fertility / Pregnancy / Postpartum Support (if applicable)
Legal / Forensic Issues (choose any that apply)?
*
Court Proceedings
Child Safety Involvement
Domestic Violence Orders (DVO/AVO/IVO)
Workplace /Insurance Legal Matters
Medico-Legal Reports
Not Applicable
Other
Parenting Orders & Child-Related Arrangements.
*
Parenting orders (court-issued)
Parenting plan (written agreement)
Informal/shared arrangements between parents
Sole parental responsibility
Joint parental responsibility
I am unsure
Not applicable
Other
Do you have any of the following? (optional)
Hearing support
Vision support
Mobility needs
Sensory sensitivities
Communication preferences
Cognitive/processing needs
Accessible seating
Not applicable
How did you hear about us
*
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I understand that my information will be kept confidential and stored securely. I acknowledge that the OCD Clinic operates as a full-fee service and that this form is for non-urgent enquiries. I am aware that submitting this form does not guarantee an appointment, and that the clinic will contact me regarding availability. I agree to be contacted using the details provided.
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