Appointment Request
Anxiety House Sunshine Coast
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 immediate risk, please contact emergency services, GP, Lifeline 131 114 or 000.
All fields marked with * are required and must be filled.
Name
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First Name
Last Name
Date of Birth
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/
Day
/
Month
Year
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What are your pronouns?
*
She/Her
He/Him
They/Them
Prefer not to say
Other
Who is the appointment for?
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Adult
Adolescent
Child
Email
*
example@example.com
Contact Number
*
Enter your mobile or best contact phone number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Method
*
Phone
Email
SMS
Preferred days/times
*
Monday
Tuesday
Wednesday
Thursday
Friday
When do appointments generally suit you best?
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Morning
Afternoon
Either is fine
Appointment preference
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In person
Telehealth
Either
Legal / Forensic Issues (choose any that apply)?
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Court Proceedings
Child Safety Involvement
Domestic Violence Orders (DVO/AVO/IVO)
Police Involvement
Criminal Charges
Victim Impact Matters
Workplace Legal Matters
Insurance Claims
Compensation or Medico-Legal Reports
Tribunal Matters (e.g., QCAT)
Immigration or Visa-Related Assessments
Driving or Firearms
Probation or Parole Involvement
Not Applicable
Other
Presenting Concerns (tick that apply)
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OCD Concerns
Excessive worry
Panic Attacks
Social Anxiety
Health Anxiety
Phobias or Specific Fears
Low Mood or Depression
Stress or Overwhelm
Autism/ Neurodivergence
Attention or Focus Difficulties
Sensory Sensitivity
LGBTQIA+ Identity or Gender-Related Concerns
Binge Eating or Body Image Issues
Skin Picking
Hair Pulling (Trichotillomania)
Hoarding Disorder
Other
Do you have any accessibility, mobility, disability, cultural, or communication needs you would like us to be aware of?
How did you hear about us?
*
Google Search
Our Website
Instagram
Facebook
LinkedIn
Youtube
Podcast or Online Content
GP Referral
Psychiatrist Referral
Psychologist or Allied Health Referral
Friend or Family Recommendation
School or University Referral
Existing Client returning
Workplace / Employee Assistance Program
Online Directory (e.g. PsychologyToday, HealthDirect)
Event, Webinar or Workshop
Other
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All fields marked with * are required and must be filled.
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I understand that the information provided is confidential and securely stored. I acknowledge that the Anxiety House Sunshine Coast Clinic is 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 about availability. I agree to be contacted using the details I have provided.
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NO
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