Intake Questionnaire

Intake Questionnaire
About You
Name*

First NameLast Name
Do you have a preferred name you like to be called? (Please leave blank if you do not have one)
What is your preferred salutation?
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

DayMonthYear
Date
Do you identify as Aboriginal or Torres Straight Islander?*

YesNo
Date completing this form:*

DayMonthYear
Date
Therapy
What are your main concerns/reasons for wanting to commence therapy? (please go into as much or as little detail as you'd prefer)*
Our practice only provides sessions online via zoom or via telephone. Is this ok with you?*

YesNo
Who is your GP and/or GP Practice name?*
Do you have a current Mental Health Care Plan?*

YesNo
How did you hear about us?*
Do you know of anyone who has sought therapy at Annie Slater Psychology?*
If yes, what is your relationship with this person? And which clinician did they see?
How urgent is your need for therapy? (eg: I could wait a few weeks, I need something asap?...)*
Other
Do you have a medical condition you would like us to be made aware of? (If yes please write it here)*
Are you currently seeing a Psychiatrist? (Please state their name and/or practice)*
Have you seen one in the past?*

YesNo
Have you had any previous therapy? (If yes, please provide how you found it and approx' how long you were attending)*
How is your support network? (family, friends, co-workers etc)*
Do you have concerns with your relationships? (with family, friends, work, partner/spouse)*
Are you in danger of hurting yourself or others at the moment?*

YesNo
Has this been a problem in the past?*

YesNo
Consent and Confidentiality:
A consent form will be sent to you in a separate email - please read through this carefully and sign. We will then keep this information on your file. If you ever need to update any details you have provided via this form or if you have any other questions, please either call or send an email to the contact details below:

Thank you for taking the time to complete this form, this will assist us further in being able to offer therapy services to you.

Our contact details are as follows:
| P: 0447 332 708 | E: annieslaterpsychology@gmail.com | F: (02) 8024 2602 | W: www.annieslaterpsychology.com
Should be Empty:

Intake Questionnaire

About You

Therapy

Other

Consent and Confidentiality: