Anxiety House Brisbane Appointment Request

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Date of Birth* This field is required.

Date

4

Contact Number* This field is required.

Enter your mobile or best contact phone number

5

What are your main concerns?* This field is required.

6

Are you currently being managed by NDIS?

Yes, plan managed.

Yes, self managed.

No.

7

Have you seen a psychologist or psychiatrist before?* This field is required.

YESNO

8

Are you currently taking any medication?* This field is required.

9

What are your best days and times for appointments?* This field is required.

10

Do you have a preference of clinician?* This field is required.eg. John Smith, I don't mind, whoever you recommend. Please see our team here: https://anxietyhouse.com.au/about/

11

If the new client is a child - do you currently have a Parenting Agreement in place for your child?

Yes

No

12

If you currently have a Parenting Agreement in place for your child, please provide additional information.

13

Do you have a preference of clinic location?* This field is required.Please note, we try our best to accommodate your location preferences, however clinician availability may vary

Northside - Paddington

Southside - Bulimba

I don't mind

14

Are you open to telehealth video or phone consultations?* This field is required.

Yes, I'm open to telehealth appointments

No, I only want face to face appointments

I don't mind either way

15

What personality traits would you like in a therapist?* This field is required.

16

What type of therapy do you prefer?* This field is required.

17

How did you hear about us?* This field is required.